Healthcare Provider Details

I. General information

NPI: 1841309929
Provider Name (Legal Business Name): MARCO TULIO FAJARDO JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 W DIEHL RD
NAPERVILLE IL
60563-1277
US

IV. Provider business mailing address

340 TUPELO AVE
NAPERVILLE IL
60540-7828
US

V. Phone/Fax

Practice location:
  • Phone: 630-393-3045
  • Fax: 630-393-3920
Mailing address:
  • Phone: 630-327-9295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-023251
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: