Provider Demographics
NPI:1144893488
Name:FATTAL, AMINE
Entity type:Individual
Prefix:
First Name:AMINE
Middle Name:
Last Name:FATTAL
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 1:23618 US HIGHWAY 33
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-3608
Mailing Address - Country:US
Mailing Address - Phone:574-875-8196
Mailing Address - Fax:
Practice Address - Street 1:23618 US HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-3608
Practice Address - Country:US
Practice Address - Phone:574-875-8196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014217A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics