Healthcare Provider Details

I. General information

NPI: 1548353295
Provider Name (Legal Business Name): MARCIO A DAFONSECA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S. 18TH STREET
COLUMBUS OH
43205
US

IV. Provider business mailing address

555 S. 18TH STREET
COLUMBUS OH
43205
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-4579
  • Fax: 614-722-4565
Mailing address:
  • Phone: 614-722-4579
  • Fax: 614-722-4565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number71000193
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: