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General NPI Number Information
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NPI Number | 1528792835
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Entity Type | Individual
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Provider Name | MITCHELL TIMOTHY FACKLER DDS
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Gender | Male
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Dates
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Enumeration Date | 07/12/2022
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Last Update Date | 04/19/2023
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Provider Practice Location Address
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Address Line | 968 1ST INFANTRY DIVISION RD
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City | FORT KNOX
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State | KY
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Zip | 40121-5210
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Country | US
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Telephone | 502-626-8314
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Fax |
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Provider Business Mailing Address
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Address Line | 5879 ADAMS ST # A
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City | FORT KNOX
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State | KY
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Zip | 40121-4001
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Country | US
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Telephone | 502-626-8314
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901601406
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License Number State | MI
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