Provider Demographics
NPI:1831101682
Name:FASTEAU, HENRY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:A
Last Name:FASTEAU
Suffix:
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 1:14700 MUSTANG PATH
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21738
Mailing Address - Country:US
Mailing Address - Phone:410-442-2526
Mailing Address - Fax:
Practice Address - Street 1:5042 DORSEY HALL DR
Practice Address - Street 2:STE 102
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042
Practice Address - Country:US
Practice Address - Phone:410-964-3020
Practice Address - Fax:410-964-3021
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD66801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice