Provider Demographics
NPI:1194491514
Name:MDANAT, FADI KHALED AEADAH
Entity type:Individual
Prefix:
First Name:FADI
Middle Name:KHALED AEADAH
Last Name:MDANAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 MAIN ST APT 338
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-8178
Mailing Address - Country:US
Mailing Address - Phone:305-440-6604
Mailing Address - Fax:
Practice Address - Street 1:1912 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4736
Practice Address - Country:US
Practice Address - Phone:419-219-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26284122300000X
OH30.0266431223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist