Provider Demographics
NPI:1811911480
Name:HISHMEH, FAHED BASEM (DMD)
Entity type:Individual
Prefix:DR
First Name:FAHED
Middle Name:BASEM
Last Name:HISHMEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-1536
Mailing Address - Country:US
Mailing Address - Phone:606-348-5100
Mailing Address - Fax:606-348-4849
Practice Address - Street 1:650 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-1536
Practice Address - Country:US
Practice Address - Phone:606-348-5100
Practice Address - Fax:606-348-4849
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000098Medicaid
KY45003571OtherPRIOR AUTH.# FOR MEDICAID