Provider Demographics
NPI:1366982373
Name:KIDWAI, FAHAD
Entity type:Individual
Prefix:
First Name:FAHAD
Middle Name:
Last Name:KIDWAI
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 1:848 NEW MARK ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2750
Mailing Address - Country:US
Mailing Address - Phone:201-685-2295
Mailing Address - Fax:
Practice Address - Street 1:848 NEW MARK ESPLANADE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2750
Practice Address - Country:US
Practice Address - Phone:201-685-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2002097075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD53231968OtherKAISER