Provider Demographics
NPI:1366764474
Name:EDALAT, FARIBA (DDS)
Entity type:Individual
Prefix:DR
First Name:FARIBA
Middle Name:
Last Name:EDALAT
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 1:29 SCHINDLER TER
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1079
Mailing Address - Country:US
Mailing Address - Phone:973-736-0642
Mailing Address - Fax:
Practice Address - Street 1:639 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3109
Practice Address - Country:US
Practice Address - Phone:973-481-3900
Practice Address - Fax:973-481-2999
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI22496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0233552Medicaid