Provider Demographics
NPI:1366560716
Name:FARIBA RAFIZADEH, D.M.D. P.A.
Entity type:Organization
Organization Name:FARIBA RAFIZADEH, D.M.D. P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIBA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:301-948-5656
Mailing Address - Street 1:902 WIND RIVER LN STE 204
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1977
Mailing Address - Country:US
Mailing Address - Phone:301-948-5656
Mailing Address - Fax:301-519-9164
Practice Address - Street 1:902 WIND RIVER LN STE 204
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1977
Practice Address - Country:US
Practice Address - Phone:301-948-5656
Practice Address - Fax:301-519-9164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12428261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12428OtherMARYLAND STATE LICENSE