Provider Demographics
NPI:1114194875
Name:FAHEY, BRIAN ASHLEY (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ASHLEY
Last Name:FAHEY
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 1:2447 MISSION AVE
Mailing Address - Street 2:STE A
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4910
Mailing Address - Country:US
Mailing Address - Phone:916-483-2484
Mailing Address - Fax:916-483-1500
Practice Address - Street 1:2447 MISSION AVE
Practice Address - Street 2:STE A
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4910
Practice Address - Country:US
Practice Address - Phone:916-483-2484
Practice Address - Fax:916-483-1500
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice