Provider Demographics
NPI:1356847297
Name:FARID, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:FARID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N WASHINGTON AVE STE W102
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-2450
Mailing Address - Country:US
Mailing Address - Phone:856-222-3445
Mailing Address - Fax:
Practice Address - Street 1:12 YUCCA DR
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1634
Practice Address - Country:US
Practice Address - Phone:646-251-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-31
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060874-01122300000X
390200000X
NJ22DI02757400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program