Provider Demographics
NPI:1164885547
Name:FAZZONE, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FAZZONE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 COMELY LN
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-5230
Mailing Address - Country:US
Mailing Address - Phone:518-281-0663
Mailing Address - Fax:
Practice Address - Street 1:530 SOUTH WAKARA WAY
Practice Address - Street 2:UNIVERSITY OF URAH, SCHOOL OF DENTISTRY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-581-8951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program