Basic Information
| Provider Information | |||||||||
| NPI: | 1487810628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARAG | ||||||||
| FirstName: | KATRINE | ||||||||
| MiddleName: | ATTIA | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339021357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392783600 | ||||||||
| FaxNumber: | 2392783203 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 LEE BLVD | ||||||||
| Address2: | UNITS 101-104 | ||||||||
| City: | LEHIGH ACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339711309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393442385 | ||||||||
| FaxNumber: | 2393685460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN18366 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000383600 | 05 | FL | MEDICAID |