Provider Demographics
NPI:1417040940
Name:FANDEL, JAY EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:EDWARD
Last Name:FANDEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5618 WOODBINE LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904
Mailing Address - Country:US
Mailing Address - Phone:325-654-3676
Mailing Address - Fax:
Practice Address - Street 1:2102 PECOS ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3061
Practice Address - Country:US
Practice Address - Phone:325-944-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2612-91122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist