Provider Demographics
NPI:1275150799
Name:FAJARDO, JUAN JOSE (DMD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4789 SW 148TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-2121
Mailing Address - Country:US
Mailing Address - Phone:954-252-5911
Mailing Address - Fax:
Practice Address - Street 1:4789 SW 148TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-2121
Practice Address - Country:US
Practice Address - Phone:954-252-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRP2164122300000X
FLDN251941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentist