Provider Demographics
NPI:1164473484
Name:FARD, RAMBOD S (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAMBOD
Middle Name:S
Last Name:FARD
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 1:2713 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2255
Mailing Address - Country:US
Mailing Address - Phone:608-442-4400
Mailing Address - Fax:
Practice Address - Street 1:2713 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2255
Practice Address - Country:US
Practice Address - Phone:608-442-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5840-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33794000Medicaid