Provider Demographics
NPI:1346247376
Name:FANSA, MALEK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALEK
Middle Name:
Last Name:FANSA
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 1:75 N STATE ROAD 135
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1456
Mailing Address - Country:US
Mailing Address - Phone:317-885-7006
Mailing Address - Fax:317-885-7099
Practice Address - Street 1:75 N STATE ROAD 135
Practice Address - Street 2:SUITE C
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1456
Practice Address - Country:US
Practice Address - Phone:317-885-7006
Practice Address - Fax:317-885-7099
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010260A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice