Provider Demographics
NPI:1871345652
Name:FAIN, AVERY NICOLETTE
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:NICOLETTE
Last Name:FAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 OLD KEMP HWY
Mailing Address - Street 2:
Mailing Address - City:KAUFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75142-3658
Mailing Address - Country:US
Mailing Address - Phone:972-932-4312
Mailing Address - Fax:
Practice Address - Street 1:2211 OLD KEMP HWY
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-3658
Practice Address - Country:US
Practice Address - Phone:972-932-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002026962124Q00000X
TX25814124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist