Provider Demographics
NPI:1437313053
Name:FARIAS, AGUSTIN LEPE
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:LEPE
Last Name:FARIAS
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 1:2200 FORT ROOTS DR # 160
Mailing Address - Street 2:VA HOSPITAL DENTAL SERVICE
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-1709
Mailing Address - Country:US
Mailing Address - Phone:210-618-8546
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DR # 160
Practice Address - Street 2:VA HOSPITAL DENTAL SERVICE
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:210-618-8546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-13
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery