Provider Demographics
NPI:1225195019
Name:FAZIO, JOHN EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:FAZIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:E
Other - Last Name:FAZIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:126 FIELDSTONE LANE
Mailing Address - Street 2:
Mailing Address - City:LIGONIER
Mailing Address - State:PA
Mailing Address - Zip Code:15658
Mailing Address - Country:US
Mailing Address - Phone:724-238-9637
Mailing Address - Fax:
Practice Address - Street 1:1185 E PITTSBURG
Practice Address - Street 2:STE B1
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601
Practice Address - Country:US
Practice Address - Phone:724-834-6720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026051L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist