Healthcare Provider Details

I. General information

NPI: 1811561293
Provider Name (Legal Business Name): TEXAS TECH UNIVERSITY HSC AT EL WLH SCHOOL OF DENTAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/19/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 RICK FRANCIS ST
EL PASO TX
79905-2817
US

IV. Provider business mailing address

5001 EL PASO DRIVE, MSC 24002
EL PASO TX
79905
US

V. Phone/Fax

Practice location:
  • Phone: 915-215-6700
  • Fax: 915-215-4726
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. FADY FADDOUL
Title or Position: ASSOCIATE DEAN OF CLINICAL AFFAIRS
Credential: DDS, MSD
Phone: 915-215-4579