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General NPI Number Information
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NPI Number | 1932321007
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Entity Type | Organization
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Legal Business Name | FARESE FAMILY DENTAL
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2212 JACKSON AVE W
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City | OXFORD
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State | MS
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Zip | 38655-5409
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Country | US
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Telephone | 662-234-8463
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Fax |
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Provider Business Mailing Address
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Address Line | 522 WEDGEWOOD
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City | OXFORD
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State | MS
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Zip | 38655-5409
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Country | US
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Telephone | 662-315-5834
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | LEA M FARESE
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Credential | D.M.D.
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Telephone | 662-234-8463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3231-02
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3293-04
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License Number State | MS
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