Provider Demographics
NPI:1225463433
Name:ERIC FAYZIEV DDS PA
Entity Type:Organization
Organization Name:ERIC FAYZIEV DDS PA
Other - Org Name:MULVANE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYZIEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:316-777-1151
Mailing Address - Street 1:1210 N ROCK RD
Mailing Address - Street 2:
Mailing Address - City:MULVANE
Mailing Address - State:KS
Mailing Address - Zip Code:67110-1118
Mailing Address - Country:US
Mailing Address - Phone:316-777-1151
Mailing Address - Fax:
Practice Address - Street 1:1210 N ROCK RD
Practice Address - Street 2:
Practice Address - City:MULVANE
Practice Address - State:KS
Practice Address - Zip Code:67110-1118
Practice Address - Country:US
Practice Address - Phone:316-777-1151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS608001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty