Provider Demographics
NPI:1609269380
Name:FA DENTAL PLLCS
Entity Type:Organization
Organization Name:FA DENTAL PLLCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:FARNAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ATHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-275-9460
Mailing Address - Street 1:6034 PALO PINTO AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 W PIONEER PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4710
Practice Address - Country:US
Practice Address - Phone:702-275-9460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty