Basic Information
| Provider Information | |||||||||
| NPI: | 1164885547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAZZONE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 COMELY LN | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121105230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182810663 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 SOUTH WAKARA WAY | ||||||||
| Address2: | UNIVERSITY OF URAH, SCHOOL OF DENTISTRY | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015818951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.