Provider Demographics
NPI:1205134772
Name:FATA, TERRI (RDH)
Entity type:Individual
Prefix:MISS
First Name:TERRI
Middle Name:
Last Name:FATA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38372 TIMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2688
Mailing Address - Country:US
Mailing Address - Phone:734-207-6297
Mailing Address - Fax:
Practice Address - Street 1:559 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-2200
Practice Address - Country:US
Practice Address - Phone:313-554-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902008635124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist