Provider Demographics
NPI:1801817002
Name:FASANO, MARYBETH (DMD)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:FASANO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454
Mailing Address - Country:US
Mailing Address - Phone:757-412-2235
Mailing Address - Fax:757-412-2237
Practice Address - Street 1:984 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454
Practice Address - Country:US
Practice Address - Phone:757-412-2235
Practice Address - Fax:757-412-2237
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
153899OtherANTHEM
980759OtherUNITED CONCORDIA