MEDICARE: FAHRA MERCHANT DMD

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	122300000X	Dentist	DE00009481	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639224660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAHRA MERCHANT DMD

Provider Business Mailing Address
First Line	:	14217 SE 83RD ST
Second Line	:
City	:	NEWCASTLE
State	:	WA
Zip	:	98059-3456
Country	:	US
Telephone Number	:	253-584-8840
Fax Number	:

Provider Business Practice Location Address
First Line	:	10518 S TACOMA WAY STE B
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98499-5400
Country	:	US
Telephone Number	:	253-584-8840
Fax Number	:

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/09/2007

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Directions to “ FAHRA MERCHANT DMD” Practice Location

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