Provider Demographics
NPI:1184753774
Name:NAWLO, FARAGE MOUSSA (DDS)
Entity type:Individual
Prefix:DR
First Name:FARAGE
Middle Name:MOUSSA
Last Name:NAWLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 A DYCKMAN STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040
Mailing Address - Country:US
Mailing Address - Phone:212-304-1728
Mailing Address - Fax:212-304-3852
Practice Address - Street 1:201 A DYCKMAN STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040
Practice Address - Country:US
Practice Address - Phone:212-304-1728
Practice Address - Fax:212-304-3852
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04747411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804695Medicaid