Provider Demographics
NPI:1336563212
Name:FADI ASSAF DDS III PLLC
Entity Type:Organization
Organization Name:FADI ASSAF DDS III PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-850-0133
Mailing Address - Street 1:2067 AMERICANA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-2176
Mailing Address - Country:US
Mailing Address - Phone:407-850-0133
Mailing Address - Fax:407-850-0485
Practice Address - Street 1:2067 AMERICANA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-2176
Practice Address - Country:US
Practice Address - Phone:407-850-0133
Practice Address - Fax:407-850-0485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009572200Medicaid