Healthcare Provider Details

I. General information

NPI: 1669963518
Provider Name (Legal Business Name): DR. FAHAD AL-FADHLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SYCAMORE RDG
MADISON MS
39110-7333
US

IV. Provider business mailing address

109 SYCAMORE RDG
MADISON MS
39110-7333
US

V. Phone/Fax

Practice location:
  • Phone: 601-954-4476
  • Fax:
Mailing address:
  • Phone: 601-898-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4071-19
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: