Healthcare Provider Details

I. General information

NPI: 1932508496
Provider Name (Legal Business Name): YETUNDE FASORO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 LAKELAND DR
CHIPPEWA FALLS WI
54729-1687
US

IV. Provider business mailing address

850 LAKELAND DR
CHIPPEWA FALLS WI
54729-1687
US

V. Phone/Fax

Practice location:
  • Phone: 715-738-2000
  • Fax:
Mailing address:
  • Phone: 715-738-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014857
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1001171-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: