Healthcare Provider Details

I. General information

NPI: 1942650635
Provider Name (Legal Business Name): JENNIFER ROSE FASOLINO EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6037 BESSINGER ST
FORT SILL OK
73503-4406
US

IV. Provider business mailing address

6037 BESSINGER ST
FORT SILL OK
73503-4406
US

V. Phone/Fax

Practice location:
  • Phone: 580-442-5544
  • Fax:
Mailing address:
  • Phone: 580-442-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: