Provider Demographics
NPI:1316716426
Name:FADDA, SAJA
Entity type:Individual
Prefix:
First Name:SAJA
Middle Name:
Last Name:FADDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7457 DOUBLOON DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9114
Mailing Address - Country:US
Mailing Address - Phone:616-821-7911
Mailing Address - Fax:
Practice Address - Street 1:10451 STELLING DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578
Practice Address - Country:US
Practice Address - Phone:813-359-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX400761223G0001X
FLDN287031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice