MEDICARE: JENNA FARRAJ

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	30.027198	OH

General Provider Information

NPI Number	:	1871286096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA FARRAJ

Provider Business Mailing Address
First Line	:	5915 PARK RIDGE DR
Second Line	:
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-4140
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17117 DETROIT AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-3622
Country	:	US
Telephone Number	:	216-221-0300
Fax Number	:

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

Provider Enumeration Date	:	06/01/2023
Last Update Date	:	06/01/2023

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