Provider Demographics
NPI:1003114471
Name:ZAMUDIO, FABIOLA (RDH)
Entity Type:Individual
Prefix:MISS
First Name:FABIOLA
Middle Name:
Last Name:ZAMUDIO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 WARWICK AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-4705
Mailing Address - Country:US
Mailing Address - Phone:313-645-9666
Mailing Address - Fax:
Practice Address - Street 1:559 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-2200
Practice Address - Country:US
Practice Address - Phone:313-554-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902015931124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist