Provider Demographics
NPI:1265815997
Name:AL FARAWATI, FADI (DDS, MS, MCLINDENT)
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:
Last Name:AL FARAWATI
Suffix:
Gender:M
Credentials:DDS, MS, MCLINDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 HUNTERS CV
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6903
Mailing Address - Country:US
Mailing Address - Phone:786-304-3793
Mailing Address - Fax:
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0415
Practice Address - Country:US
Practice Address - Phone:706-721-2696
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX359621223P0700X
GADNF0004051223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics