Provider Demographics
NPI:1598883837
Name:FARES, HAYTHAM A (DDS)
Entity Type:Individual
Prefix:DR
First Name:HAYTHAM
Middle Name:A
Last Name:FARES
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 1:22190 GARRISON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2235
Mailing Address - Country:US
Mailing Address - Phone:313-561-7070
Mailing Address - Fax:313-561-0686
Practice Address - Street 1:22190 GARRISON ST STE 200
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2235
Practice Address - Country:US
Practice Address - Phone:313-561-7070
Practice Address - Fax:313-561-0686
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010170221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice