Provider Demographics
NPI:1639183916
Name:FAGGIONI, MARTINO SYLVESTER JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTINO
Middle Name:SYLVESTER
Last Name:FAGGIONI
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 MONTREAL ROAD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6931
Mailing Address - Country:US
Mailing Address - Phone:770-038-1848
Mailing Address - Fax:770-938-1856
Practice Address - Street 1:1462 MONTREAL RD
Practice Address - Street 2:SUITE 211
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:770-038-1848
Practice Address - Fax:770-938-1856
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100190OtherAVESIS PROVIDER NUMBER
GA9180034OtherDORAL DENTAL USA PROVIDER
GA000202243BMedicaid