Provider Demographics
NPI:1033856703
Name:BARSOUM, FADY (DDS)
Entity Type:Individual
Prefix:
First Name:FADY
Middle Name:
Last Name:BARSOUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TUESMAN WAY
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6H7M8
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1548
Practice Address - Country:US
Practice Address - Phone:716-508-4547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY063469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program