Provider Demographics
NPI:1376068601
Name:FARNOUSH, MICHELLE (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:FARNOUSH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8650 SPRING MOUNTAIN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-4106
Mailing Address - Country:US
Mailing Address - Phone:702-869-0032
Mailing Address - Fax:
Practice Address - Street 1:2095 VILLAGE CENTER CIR STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-6253
Practice Address - Country:US
Practice Address - Phone:702-240-0400
Practice Address - Fax:702-240-0400
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV69481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice