Provider Demographics
NPI:1629207196
Name:FAZYLOVA, HELEN V (DMD)
Entity Type:Individual
Prefix:DR
First Name:HELEN
Middle Name:V
Last Name:FAZYLOVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:HELEN
Other - Middle Name:V
Other - Last Name:CARDACIOTTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:15816 LEMOYNE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-4048
Mailing Address - Country:US
Mailing Address - Phone:228-207-0046
Mailing Address - Fax:228-207-0047
Practice Address - Street 1:15816 LEMOYNE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-4019
Practice Address - Country:US
Practice Address - Phone:228-207-0046
Practice Address - Fax:228-207-0047
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014129011223G0001X
MS3576-101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08284523Medicaid