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General NPI Number Information
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NPI Number | 1861971616
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Entity Type | Individual
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Provider Name | FARAH IMAD HAZIM
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Gender | Female
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Dates
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Enumeration Date | 08/13/2018
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Last Update Date | 01/04/2021
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Provider Practice Location Address
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Address Line | 13874 GRAND RIVER AVE
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City | DETROIT
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State | MI
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Zip | 48227-3123
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Country | US
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Telephone | 313-651-7260
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Fax |
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Provider Business Mailing Address
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Address Line | 9789 MAGNOLIA AVE
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City | RIVERSIDE
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State | CA
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Zip | 92503-3642
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Country | US
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Telephone | 951-352-6300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901022750
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 105876
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License Number State | CA
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