Provider Demographics
NPI:1891280673
Name:FAIRVIEW DENTAL LLC
Entity Type:Organization
Organization Name:FAIRVIEW DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-728-5042
Mailing Address - Street 1:210 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2704
Mailing Address - Country:US
Mailing Address - Phone:281-728-5042
Mailing Address - Fax:
Practice Address - Street 1:210 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2704
Practice Address - Country:US
Practice Address - Phone:281-728-5042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMTECH DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015055261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental