Provider Demographics
NPI:1295296168
Name:FAZZOLARI, JUSTIN RIECE (DMD, MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RIECE
Last Name:FAZZOLARI
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 57TH ST STE 804
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3217
Mailing Address - Country:US
Mailing Address - Phone:646-895-9680
Mailing Address - Fax:
Practice Address - Street 1:200 W 57TH ST STE 804
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3217
Practice Address - Country:US
Practice Address - Phone:646-895-9680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI030287001223S0112X
NY0650031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery