Provider Demographics
NPI:1487810628
Name:FARAG, KATRINE ATTIA (DMD)
Entity type:Individual
Prefix:
First Name:KATRINE
Middle Name:ATTIA
Last Name:FARAG
Suffix:
Gender:F
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:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-1357
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-278-3203
Practice Address - Street 1:3400 LEE BLVD
Practice Address - Street 2:UNITS 101-104
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1309
Practice Address - Country:US
Practice Address - Phone:239-344-2385
Practice Address - Fax:239-368-5460
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN183661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000383600Medicaid