Provider Demographics
NPI:1053759910
Name:FARDOUS, SAHAR A (DDS)
Entity type:Individual
Prefix:DR
First Name:SAHAR
Middle Name:A
Last Name:FARDOUS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26561 W 12 MILE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1541
Mailing Address - Country:US
Mailing Address - Phone:248-864-7400
Mailing Address - Fax:248-864-7401
Practice Address - Street 1:26561 W 12 MILE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1541
Practice Address - Country:US
Practice Address - Phone:248-864-7400
Practice Address - Fax:248-864-7401
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010209981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice