Provider Demographics
NPI:1376509117
Name:FARAGE, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:FARAGE
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 1:6650 CROSSING DR.SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-554-0296
Mailing Address - Fax:616-554-9981
Practice Address - Street 1:6650 CROSSING DR.SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508
Practice Address - Country:US
Practice Address - Phone:616-554-0296
Practice Address - Fax:616-554-9981
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice