Provider Demographics
NPI:1275138265
Name:FATHI, ROAA GHASSAN I
Entity Type:Individual
Prefix:MISS
First Name:ROAA
Middle Name:GHASSAN
Last Name:FATHI
Suffix:I
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 1:5021 NW 34TH BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-1191
Mailing Address - Country:US
Mailing Address - Phone:352-371-7766
Mailing Address - Fax:
Practice Address - Street 1:5021 NW 34TH BLVD STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-1191
Practice Address - Country:US
Practice Address - Phone:352-371-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25085124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist