Basic Information
| Provider Information | |||||||||
| NPI: | 1962894683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE FAZIO | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2000 SALZEDO ST APT 418 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547701666 | ||||||||
| FaxNumber: | 6515238584 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ALHAMBRA PLZ STE 25 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331345216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865074440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2015 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D13646 | MN | N | Dental Providers | Dentist | 122300000X | DN21777 | FL | Y | Dental Providers | Dentist |
No ID Information.