Healthcare Provider Details

I. General information

NPI: 1497251961
Provider Name (Legal Business Name): MICHELLE FACKLER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 FULTON ST
FARMINGDALE NY
11735-3454
US

IV. Provider business mailing address

19 ROBERTA LN
COMMACK NY
11725-3815
US

V. Phone/Fax

Practice location:
  • Phone: 516-249-1188
  • Fax:
Mailing address:
  • Phone: 516-661-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number069155
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: