Provider Demographics
NPI:1619539814
Name:FADLER, KATHLEEN RUTH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:RUTH
Last Name:FADLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 N DAVIS RD APT 922
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-1616
Mailing Address - Country:US
Mailing Address - Phone:678-860-6792
Mailing Address - Fax:
Practice Address - Street 1:313 MOOTY BRIDGE RD STE 202
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-1809
Practice Address - Country:US
Practice Address - Phone:706-837-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0159121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice