Healthcare Provider Details

I. General information

NPI: 1184536971
Provider Name (Legal Business Name): GABRIELLE FADLY
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S GRAND AVE STE 204
LOS ANGELES CA
90012-3035
US

IV. Provider business mailing address

18017 CHATSWORTH ST # 416
GRANADA HILLS CA
91344-5608
US

V. Phone/Fax

Practice location:
  • Phone: 213-451-4757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: