Provider Demographics
NPI:1831233832
Name:FANOUS, NAGWA B (DMD)
Entity type:Individual
Prefix:MRS
First Name:NAGWA
Middle Name:B
Last Name:FANOUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757
Mailing Address - Country:US
Mailing Address - Phone:508-478-0106
Mailing Address - Fax:508-478-3247
Practice Address - Street 1:2 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-478-0106
Practice Address - Fax:508-478-3247
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAM15660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0264091Medicaid