Provider Demographics
NPI:1346953387
Name:MOURI, FARHANA MANNAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:FARHANA
Middle Name:MANNAN
Last Name:MOURI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 LOU ANN DR APT 216
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6520
Mailing Address - Country:US
Mailing Address - Phone:209-362-7042
Mailing Address - Fax:
Practice Address - Street 1:2605 COFFEE RD STE 200
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2064
Practice Address - Country:US
Practice Address - Phone:209-521-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS108433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist