Provider Demographics
NPI:1720597982
Name:FAHL, KAY ANDREA (RDH)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:ANDREA
Last Name:FAHL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 NW BARSTOW ST STE 305
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3771
Mailing Address - Country:US
Mailing Address - Phone:262-544-7645
Mailing Address - Fax:262-544-2828
Practice Address - Street 1:210 NW BARSTOW ST STE 305
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3771
Practice Address - Country:US
Practice Address - Phone:262-544-7645
Practice Address - Fax:262-544-2828
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4706-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist