Provider Demographics
NPI:1851447684
Name:ALFONZO, FARA AMELIA (DDS)
Entity Type:Individual
Prefix:
First Name:FARA
Middle Name:AMELIA
Last Name:ALFONZO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13621 SW 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33158-1029
Mailing Address - Country:US
Mailing Address - Phone:305-255-7352
Mailing Address - Fax:
Practice Address - Street 1:13621 SW 84 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33158
Practice Address - Country:US
Practice Address - Phone:305-975-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0110201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice