Provider Demographics
NPI:1669439774
Name:FARISH, SAM E (DMD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:E
Last Name:FARISH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1365B CLIFTON RD NE
Mailing Address - Street 2:STE 2300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322
Mailing Address - Country:US
Mailing Address - Phone:404-778-4500
Mailing Address - Fax:404-778-5879
Practice Address - Street 1:1365B CLIFTON RD NE
Practice Address - Street 2:STE 2300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-778-4500
Practice Address - Fax:404-778-5879
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA7556204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
19NCBTQMedicare ID - Type Unspecified
U63508Medicare UPIN