=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124799408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAY NAZARI, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2021
-----------------------------------------------------
Last Update Date | 09/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1899 E ROSEVILLE PKWY
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-7979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-787-1199
-----------------------------------------------------
Fax | 916-787-0400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 CHAMBERSBURG WAY
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-6553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-707-3028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | FAY NAZARI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 410-707-3028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------