Healthcare Provider Details

I. General information

NPI: 1033856703
Provider Name (Legal Business Name): FADY BARSOUM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 SHERIDAN DR
AMHERST NY
14226-1548
US

IV. Provider business mailing address

1100 TUESMAN WAY
OAKVILLE ONTARIO
L6H7M8
CA

V. Phone/Fax

Practice location:
  • Phone: 716-508-4547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number063469
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: