Healthcare Provider Details

I. General information

NPI: 1013106350
Provider Name (Legal Business Name): FADY FOUAD FADDOUL DDS,MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 05/24/2021
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 24001
EL PASO TX
79905
US

V. Phone/Fax

Practice location:
  • Phone: 915-215-6700
  • Fax: 216-368-6310
Mailing address:
  • Phone: 915-215-4579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37064
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: