Provider Demographics
NPI:1215387402
Name:GARCIA, FABIANA (RDH)
Entity Type:Individual
Prefix:MS
First Name:FABIANA
Middle Name:
Last Name:GARCIA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18139 NE COUCH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-7281
Mailing Address - Country:US
Mailing Address - Phone:503-489-1760
Mailing Address - Fax:
Practice Address - Street 1:18139 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-7281
Practice Address - Country:US
Practice Address - Phone:503-489-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR124Q00000X305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization