Provider Demographics
NPI:1619076783
Name:FAHEY, MICHAEL DENNIS (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DENNIS
Last Name:FAHEY
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:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:WINNIE
Mailing Address - State:TX
Mailing Address - Zip Code:77665
Mailing Address - Country:US
Mailing Address - Phone:409-296-4149
Mailing Address - Fax:409-296-4711
Practice Address - Street 1:502 3RD STREET
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665
Practice Address - Country:US
Practice Address - Phone:409-296-4149
Practice Address - Fax:409-296-4711
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice