Provider Demographics
NPI:1114067071
Name:FANDAKLY, RITA
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:
Last Name:FANDAKLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2098 MEADOW REED DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2743
Mailing Address - Country:US
Mailing Address - Phone:586-506-4800
Mailing Address - Fax:
Practice Address - Street 1:20737 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4503
Practice Address - Country:US
Practice Address - Phone:586-294-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010191321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice