Healthcare Provider Details

I. General information

NPI: 1477609774
Provider Name (Legal Business Name): MICHAEL ANTHONY FABIO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVE 314
SPRINGFIELD VA
22150-2522
US

IV. Provider business mailing address

6120 BRANDON AVE 314
SPRINGFIELD VA
22150-2522
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-0000
  • Fax:
Mailing address:
  • Phone: 703-569-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401004759
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: