Provider Demographics
NPI:1982260121
Name:HUSSAIN, FARYAL (DMD)
Entity type:Individual
Prefix:DR
First Name:FARYAL
Middle Name:
Last Name:HUSSAIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 SW 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3478
Mailing Address - Country:US
Mailing Address - Phone:954-319-5872
Mailing Address - Fax:
Practice Address - Street 1:6871 DANIELS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1510
Practice Address - Country:US
Practice Address - Phone:239-288-0537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL24124122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty