Provider Demographics
NPI:1245648518
Name:FARIDA, JAKE (DDS)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:FARIDA
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 1:2050 PINE LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1307
Mailing Address - Country:US
Mailing Address - Phone:248-860-1286
Mailing Address - Fax:
Practice Address - Street 1:7125 ORCHARD LAKE RD STE 310
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3620
Practice Address - Country:US
Practice Address - Phone:248-855-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010212561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice