Provider Demographics
NPI:1972097285
Name:FAKHARI, FAZEL
Entity Type:Individual
Prefix:DR
First Name:FAZEL
Middle Name:
Last Name:FAKHARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8537 SCHOLARS LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-2019
Mailing Address - Country:US
Mailing Address - Phone:240-599-6341
Mailing Address - Fax:
Practice Address - Street 1:12800 MIDDLEBROOK RD STE 104
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-5204
Practice Address - Country:US
Practice Address - Phone:301-353-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD164621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice