=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558305656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP FOREST FABEL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 03/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 LAKE RD
-----------------------------------------------------
City | ROBBINSDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-537-1292
-----------------------------------------------------
Fax | 763-537-1468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 LAKE RD
-----------------------------------------------------
City | ROBBINSDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-537-1292
-----------------------------------------------------
Fax | 763-537-1468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7299
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------