Provider Demographics
NPI:1063661361
Name:FADARE, OMALARA M (DDS)
Entity Type:Individual
Prefix:
First Name:OMALARA
Middle Name:M
Last Name:FADARE
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 1:400 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5980
Mailing Address - Country:US
Mailing Address - Phone:678-904-5665
Mailing Address - Fax:678-904-5666
Practice Address - Street 1:400 N TIMBERLAND DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-0460
Practice Address - Country:US
Practice Address - Phone:678-904-5665
Practice Address - Fax:678-904-5666
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice