Provider Demographics
NPI:1447616578
Name:FADY FAKHOURY PA
Entity Type:Organization
Organization Name:FADY FAKHOURY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FADY
Authorized Official - Middle Name:I
Authorized Official - Last Name:FAKHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:239-495-9900
Mailing Address - Street 1:10911 BONITA BEACH RD SE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-9053
Mailing Address - Country:US
Mailing Address - Phone:239-495-9900
Mailing Address - Fax:239-495-6256
Practice Address - Street 1:10911 BONITA BEACH RD SE
Practice Address - Street 2:SUITE 105
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-9053
Practice Address - Country:US
Practice Address - Phone:239-495-9900
Practice Address - Fax:239-495-6256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty