MEDICARE: DR. KATHLEEN RUTH FADLER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN015912	GA

General Provider Information

NPI Number	:	1619539814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN RUTH FADLER DMD

Provider Business Mailing Address
First Line	:	140 N DAVIS RD APT 922
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30241-1616
Country	:	US
Telephone Number	:	678-860-6792
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 MOOTY BRIDGE RD STE 202
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-1809
Country	:	US
Telephone Number	:	706-837-0123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	07/08/2019

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