Provider Demographics
NPI:1073369278
Name:FADNESS, SELA ROSE (DDS)
Entity type:Individual
Prefix:DR
First Name:SELA
Middle Name:ROSE
Last Name:FADNESS
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 1:907 18TH ST SW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-1723
Mailing Address - Country:US
Mailing Address - Phone:507-440-3963
Mailing Address - Fax:
Practice Address - Street 1:2191 DEFENSE HWY STE 210
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2942
Practice Address - Country:US
Practice Address - Phone:410-721-2610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTBD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty