Provider Demographics
NPI:1316620990
Name:FAWL, ELLEN MARY (RDH)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARY
Last Name:FAWL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9024 SNIKTAW LN
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-9408
Mailing Address - Country:US
Mailing Address - Phone:530-468-4470
Mailing Address - Fax:530-468-5908
Practice Address - Street 1:9024 SNIKTAW LN
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9408
Practice Address - Country:US
Practice Address - Phone:530-468-4470
Practice Address - Fax:530-468-5908
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH16873124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist