Provider Demographics
NPI:1417631300
Name:ALFARRA, ABDAL AZIZ (DDS)
Entity type:Individual
Prefix:
First Name:ABDAL AZIZ
Middle Name:
Last Name:ALFARRA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 4 SEASONSSHOPPING CTR STE 128
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3197
Mailing Address - Country:US
Mailing Address - Phone:603-229-8369
Mailing Address - Fax:314-205-8778
Practice Address - Street 1:1500 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3024
Practice Address - Country:US
Practice Address - Phone:314-814-8579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20230209701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics