Provider Demographics
NPI:1689347916
Name:FAJARDO BECHARA, MADELAINE
Entity Type:Individual
Prefix:
First Name:MADELAINE
Middle Name:
Last Name:FAJARDO BECHARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3695 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-4839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1249 STRONG RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-5248
Practice Address - Country:US
Practice Address - Phone:850-875-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN286421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice