Provider Demographics
NPI:1457304412
Name:FASHEMO, DEJI V (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:DEJI
Middle Name:V
Last Name:FASHEMO
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:SUITE # C-770
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-3100
Mailing Address - Fax:972-566-3200
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE # C-770
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-3100
Practice Address - Fax:972-566-3200
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171860301Medicaid
TX8C2584Medicare ID - Type Unspecified
TX171860301Medicaid