Provider Demographics
NPI:1720862022
Name:ALSHURAIM, FARES MUSSAD (DDS)
Entity Type:Individual
Prefix:
First Name:FARES
Middle Name:MUSSAD
Last Name:ALSHURAIM
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 1:1331 MOUNT HOPE AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3934
Mailing Address - Country:US
Mailing Address - Phone:585-957-1184
Mailing Address - Fax:
Practice Address - Street 1:1114 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4353
Practice Address - Country:US
Practice Address - Phone:315-788-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0632621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics