Healthcare Provider Details

I. General information

NPI: 1912416207
Provider Name (Legal Business Name): JAMES EDWARD FABE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

IV. Provider business mailing address

PO BOX 2553
SUN VALLEY ID
83353-2553
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-9363
  • Fax:
Mailing address:
  • Phone: 208-721-3826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-1704
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: