=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184536971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLE FADLY
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2026
-----------------------------------------------------
Last Update Date | 09/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 S GRAND AVE STE 204
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-3035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-451-4757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18017 CHATSWORTH ST # 416
-----------------------------------------------------
City | GRANADA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91344-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 113398
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------