Healthcare Provider Details

I. General information

NPI: 1295083798
Provider Name (Legal Business Name): CHEYANNE FAZELI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8543
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: