Provider Demographics
NPI:1497300453
Name:FARHI, MATAN MOSHE (DMD)
Entity Type:Individual
Prefix:
First Name:MATAN
Middle Name:MOSHE
Last Name:FARHI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 W ALAMEDA AVE APT 634
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80223-2199
Mailing Address - Country:US
Mailing Address - Phone:224-374-9411
Mailing Address - Fax:
Practice Address - Street 1:719 BARRON BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3314
Practice Address - Country:US
Practice Address - Phone:847-986-6724
Practice Address - Fax:312-561-4750
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.021509122300000X
CODEN.002049811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist