Provider Demographics
NPI:1265839831
Name:FAREID DENTAL CORPORATION
Entity Type:Organization
Organization Name:FAREID DENTAL CORPORATION
Other - Org Name:PACKWOOD CREEK DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FAREID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-732-1953
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:4129 S MOONEY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9147
Practice Address - Country:US
Practice Address - Phone:559-732-1953
Practice Address - Fax:559-732-1983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty