Provider Demographics
NPI:1194863134
Name:FAZIO, LEONARD THOMAS (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:THOMAS
Last Name:FAZIO
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 MAIN ST
Mailing Address - Street 2:THE PEN AND PENCIL BUILDING SUITE 2
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2257
Mailing Address - Country:US
Mailing Address - Phone:631-474-7477
Mailing Address - Fax:631-474-7427
Practice Address - Street 1:1303 MAIN ST
Practice Address - Street 2:THE PEN AND PENCIL BUILDING SUITE 2
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2257
Practice Address - Country:US
Practice Address - Phone:631-474-7477
Practice Address - Fax:631-474-7427
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0418611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice