MEDICARE: DR. FAREEDA BACCHUS DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	33831	TX

General Provider Information

NPI Number	:	1053864983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FAREEDA BACCHUS DDS, MS

Provider Business Mailing Address
First Line	:	2121 E OLTORF ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78741-4500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 E OLTORF ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78741-4500
Country	:	US
Telephone Number	:	949-800-9524
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	11/19/2021

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