Healthcare Provider Details

I. General information

NPI: 1548689532
Provider Name (Legal Business Name): CAMRON FAKHAR DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 OLD BRICK RD APT 4330
GLEN ALLEN VA
23060-6003
US

IV. Provider business mailing address

2425 OLD BRICK RD APT 4330
GLEN ALLEN VA
23060-6003
US

V. Phone/Fax

Practice location:
  • Phone: 904-210-5472
  • Fax:
Mailing address:
  • Phone: 904-210-5472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401417069
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: