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General NPI Number Information
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NPI Number | 1063661361
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Entity Type | Individual
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Provider Name | OMOLARA M FADARE DDS
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Gender | Female
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Dates
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Enumeration Date | 09/11/2008
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Last Update Date | 08/14/2024
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Provider Practice Location Address
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Address Line | 812 CHESTNUT ST
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City | BASTROP
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State | TX
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Zip | 78602-3205
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Country | US
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Telephone | 512-985-7535
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Fax |
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Provider Business Mailing Address
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Address Line | 8001 E WILLIAM CANNON DR APT 4311
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City | AUSTIN
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State | TX
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Zip | 78744-8330
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Country | US
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Telephone | 319-621-6293
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 24257
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License Number State | TX
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