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General NPI Number Information
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NPI Number | 1205049053
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Entity Type | Individual
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Provider Name | ANTHONY WILLIAM FAZIO DDS
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Gender | Male
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2600 ROUTE 112
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City | MEDFORD
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State | NY
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Zip | 11763
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Country | US
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Telephone | 631-475-3345
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Fax | 631-475-1090
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Provider Business Mailing Address
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Address Line | 111 SPRUCE DR
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City | HOLBROOK
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State | NY
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Zip | 11741
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Country | US
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Telephone | 631-207-1334
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0472071
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License Number State | NY
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