=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467999664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIRIN FAKHRI D.D.S. P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2017
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2885 E LONG LAKE RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-879-4565
-----------------------------------------------------
Fax | 248-879-4515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2885 E LONG LAKE RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-879-4565
-----------------------------------------------------
Fax | 248-879-4515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SHIRIN FAKHRI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-879-4565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901017930
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------