Provider Demographics
NPI:1700331634
Name:FARAG, MICHAEL GEORGE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:FARAG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 CENTRE ST
Mailing Address - Street 2:810
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8600
Mailing Address - Country:US
Mailing Address - Phone:617-319-9248
Mailing Address - Fax:
Practice Address - Street 1:175 CENTRE ST
Practice Address - Street 2:810
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8600
Practice Address - Country:US
Practice Address - Phone:617-319-9248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist