Provider Demographics
NPI:1114410065
Name:FAHIM, SYED ALI RAZA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:ALI RAZA
Last Name:FAHIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 WATERLOO BLVD UNIT 502
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2676
Mailing Address - Country:US
Mailing Address - Phone:973-747-2880
Mailing Address - Fax:
Practice Address - Street 1:351 W SCHUYLKILL RD STE G15A
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19465-7438
Practice Address - Country:US
Practice Address - Phone:484-948-3097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0421831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program