Provider Demographics
NPI:1104526821
Name:FARAG, RAMSIS SAMIR ADLI
Entity type:Individual
Prefix:
First Name:RAMSIS
Middle Name:SAMIR ADLI
Last Name:FARAG
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 1:616 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4841
Mailing Address - Country:US
Mailing Address - Phone:647-456-6373
Mailing Address - Fax:
Practice Address - Street 1:15103 VIRGINIA STA APT 300
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3579
Practice Address - Country:US
Practice Address - Phone:647-456-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL285801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice