Provider Demographics
NPI:1629757547
Name:FATIH-MORENO, KAYLA ELIZABETH (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:ELIZABETH
Last Name:FATIH-MORENO
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 E LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5003
Mailing Address - Country:US
Mailing Address - Phone:704-989-2321
Mailing Address - Fax:
Practice Address - Street 1:4930 E LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5003
Practice Address - Country:US
Practice Address - Phone:407-284-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist