Provider Demographics
NPI:1699200220
Name:FARWEST DENTAL GROUP
Entity type:Organization
Organization Name:FARWEST DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:DR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYOUMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-699-1549
Mailing Address - Street 1:1704 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1433
Mailing Address - Country:US
Mailing Address - Phone:310-835-5130
Mailing Address - Fax:310-835-6090
Practice Address - Street 1:1704 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-1433
Practice Address - Country:US
Practice Address - Phone:310-835-5130
Practice Address - Fax:310-835-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG8983901Medicaid