Healthcare Provider Details

I. General information

NPI: 1396665964
Provider Name (Legal Business Name): DR. FADIA SALEM BAZINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COLLEGE AVE
ALTON IL
62002-4742
US

IV. Provider business mailing address

90 MAGNOLIA DR UNIT 1209
GLEN CARBON IL
62034-1589
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-7052
  • Fax:
Mailing address:
  • Phone: 404-903-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019.037046
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: