Provider Demographics
NPI:1699379131
Name:FAJCAKOVA, GINA (RDH)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:FAJCAKOVA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2481 NE COACHMAN RD APT 204
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-1708
Mailing Address - Country:US
Mailing Address - Phone:330-240-7321
Mailing Address - Fax:
Practice Address - Street 1:7801 9TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-1108
Practice Address - Country:US
Practice Address - Phone:727-525-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH25175124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist