Provider Demographics
NPI:1083735419
Name:FAHLER, JEFFREY JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAY
Last Name:FAHLER
Suffix:
Gender:M
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:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:JEWETT
Mailing Address - State:TX
Mailing Address - Zip Code:75846-0730
Mailing Address - Country:US
Mailing Address - Phone:903-626-5196
Mailing Address - Fax:903-626-5513
Practice Address - Street 1:2720 HWY. 79 E.
Practice Address - Street 2:
Practice Address - City:JEWETT
Practice Address - State:TX
Practice Address - Zip Code:75846
Practice Address - Country:US
Practice Address - Phone:903-626-5196
Practice Address - Fax:903-626-5513
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX150321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice