Provider Demographics
NPI:1548824568
Name:FAROOQ, MUAZZAM
Entity type:Individual
Prefix:
First Name:MUAZZAM
Middle Name:
Last Name:FAROOQ
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 1:12423 EDEN LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6337
Mailing Address - Country:US
Mailing Address - Phone:703-608-2209
Mailing Address - Fax:
Practice Address - Street 1:12423 EDEN LN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6337
Practice Address - Country:US
Practice Address - Phone:703-608-2209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416512122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist