MEDICARE: THAO FAJARDO DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN17923	FL

General Provider Information

NPI Number	:	1295932184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THAO FAJARDO DMD

Provider Business Mailing Address
First Line	:	4433 BLUE MAJOR DR
Second Line	:
City	:	WINDERMERE
State	:	FL
Zip	:	34786-3192
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6735 CONROY WINDERMERE RD
Second Line	:	SUITE #202
City	:	ORLANDO
State	:	FL
Zip	:	32835-3565
Country	:	US
Telephone Number	:	407-910-1178
Fax Number	:	407-624-3724

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	09/18/2013

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