Healthcare Provider Details

I. General information

NPI: 1801372008
Provider Name (Legal Business Name): JOSEPH FAZZIO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 CASCADE RD SE STE 400
GRAND RAPIDS MI
49546-6887
US

IV. Provider business mailing address

519 ADA DR SE STE A
ADA MI
49301-9069
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-0292
  • Fax: 616-956-3251
Mailing address:
  • Phone: 616-676-9177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022574
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901022574
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: