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General NPI Number Information
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NPI Number | 1205134772
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Entity Type | Individual
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Provider Name | TERRI FATA RDH
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Gender | Female
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Dates
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Enumeration Date | 03/08/2011
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Last Update Date | 03/08/2011
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Provider Practice Location Address
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Address Line | 559 W GRAND BLVD
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City | DETROIT
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State | MI
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Zip | 48216-2200
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Country | US
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Telephone | 313-554-3880
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Fax |
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Provider Business Mailing Address
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Address Line | 38372 TIMBERLAND DR
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City | WESTLAND
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State | MI
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Zip | 48185-2688
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Country | US
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Telephone | 734-207-6297
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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 | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 2902008635
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License Number State | MI
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