Healthcare Provider Details

I. General information

NPI: 1003241860
Provider Name (Legal Business Name): RANDY SCOTT FAECHER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 SHREVEPORT HWY DENTAL SERVICE, ALEXANDRIA VA HEALTHCARE SYSTEM
PINEVILLE LA
71360-4044
US

IV. Provider business mailing address

2495 SHREVEPORT HWY DENTAL SERVICE, ALEXANDRIA VA HEALTHCARE SYSTEM
PINEVILLE LA
71360-4044
US

V. Phone/Fax

Practice location:
  • Phone: 318-466-2567
  • Fax:
Mailing address:
  • Phone: 318-466-2567
  • Fax: 318-466-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 12491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: