Healthcare Provider Details

I. General information

NPI: 1386908317
Provider Name (Legal Business Name): FADY MOURAD WADIE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 ROUTE 70 UNIT 2-D
MANASQUAN NJ
08736-2609
US

IV. Provider business mailing address

2640 ROUTE 70 UNIT 2-D
MANASQUAN NJ
08736-2609
US

V. Phone/Fax

Practice location:
  • Phone: 732-223-2334
  • Fax:
Mailing address:
  • Phone: 732-223-2334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02505900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: