Provider Demographics
NPI:1619031374
Name:SHARIFAN, FARIBA (DMD)
Entity Type:Individual
Prefix:
First Name:FARIBA
Middle Name:
Last Name:SHARIFAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3109
Mailing Address - Country:US
Mailing Address - Phone:973-481-3900
Mailing Address - Fax:973-481-2999
Practice Address - Street 1:639 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3109
Practice Address - Country:US
Practice Address - Phone:973-481-3900
Practice Address - Fax:973-481-2999
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI020295001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0110221Medicaid
NJ7943601Medicaid