Provider Demographics
NPI:1639223241
Name:FADL, REEM (DS)
Entity Type:Individual
Prefix:
First Name:REEM
Middle Name:
Last Name:FADL
Suffix:
Gender:F
Credentials:DS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:4510 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19124-3602
Practice Address - Country:US
Practice Address - Phone:215-535-1990
Practice Address - Fax:215-535-1935
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031629L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101683193Medicaid