Provider Demographics
NPI:1386326445
Name:FABIAN, RUSSEL (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:
Last Name:FABIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-4096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 E 22ND AVE
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-3193
Practice Address - Country:US
Practice Address - Phone:251-948-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007165-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist