Provider Demographics
NPI:1700959640
Name:BALAZADEH, FARANAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:FARANAK
Middle Name:
Last Name:BALAZADEH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7017 AUSTIN ST
Mailing Address - Street 2:3D
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4722
Mailing Address - Country:US
Mailing Address - Phone:718-544-4440
Mailing Address - Fax:718-233-2723
Practice Address - Street 1:7017 AUSTIN ST
Practice Address - Street 2:3D
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4722
Practice Address - Country:US
Practice Address - Phone:718-544-4440
Practice Address - Fax:718-233-2723
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0482241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02117742Medicaid