Provider Demographics
NPI:1801270996
Name:FARNOOSH, KOOSHA
Entity type:Individual
Prefix:
First Name:KOOSHA
Middle Name:
Last Name:FARNOOSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1286 STATE ROUTE 3 N #7
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1286 STATE ROUTE 3 S STE 7
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1340
Practice Address - Country:US
Practice Address - Phone:410-721-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist