Provider Demographics
NPI:1538720651
Name:GHATTAS, FATHALLAH MOHAMED FATHALLAH
Entity type:Individual
Prefix:
First Name:FATHALLAH
Middle Name:MOHAMED FATHALLAH
Last Name:GHATTAS
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 1:656 SHADOWMOSS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4421
Mailing Address - Country:US
Mailing Address - Phone:216-583-6545
Mailing Address - Fax:
Practice Address - Street 1:18070 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4602
Practice Address - Country:US
Practice Address - Phone:216-583-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.004133122300000X
FL262451223G0001X
FLDN262451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist