Healthcare Provider Details

I. General information

NPI: 1700411402
Provider Name (Legal Business Name): LAUREN FAFALAK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7621 18TH AVE
BROOKLYN NY
11214-1107
US

IV. Provider business mailing address

7621 18TH AVE
BROOKLYN NY
11214-1107
US

V. Phone/Fax

Practice location:
  • Phone: 718-256-5512
  • Fax:
Mailing address:
  • Phone: 718-256-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number062167
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: