Provider Demographics
NPI:1790423358
Name:TARBOUSH, ADAM AGHYAD (DMD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:AGHYAD
Last Name:TARBOUSH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MHD AGHYAD
Other - Middle Name:
Other - Last Name:TARBOUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1750 TIVERTON RD UNIT 27
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2368
Mailing Address - Country:US
Mailing Address - Phone:248-954-7168
Mailing Address - Fax:
Practice Address - Street 1:1340 BLANDING BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-8052
Practice Address - Country:US
Practice Address - Phone:904-639-6924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN26982122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program