Provider Demographics
NPI:1790152205
Name:TARIK JBARAH DMD LLC
Entity Type:Organization
Organization Name:TARIK JBARAH DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-632-8571
Mailing Address - Street 1:250 FAME AVE
Mailing Address - Street 2:SUITE #206
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1587
Mailing Address - Country:US
Mailing Address - Phone:717-637-0202
Mailing Address - Fax:
Practice Address - Street 1:250 FAME AVE
Practice Address - Street 2:SUITE #206
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1587
Practice Address - Country:US
Practice Address - Phone:717-637-0202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TARIK JBARAH DMD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-01
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036611261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental