Provider Demographics
NPI:1063661361
Name:FADARE, OMOLARA M (DDS)
Entity type:Individual
Prefix:
First Name:OMOLARA
Middle Name:M
Last Name:FADARE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 E WILLIAM CANNON DR APT 4311
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-8330
Mailing Address - Country:US
Mailing Address - Phone:319-621-6293
Mailing Address - Fax:
Practice Address - Street 1:812 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3205
Practice Address - Country:US
Practice Address - Phone:512-985-7535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice