Provider Demographics
NPI:1295932184
Name:FAJARDO, THAO (DMD)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:THAO
Other - Middle Name:
Other - Last Name:MAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4433 BLUE MAJOR DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-3192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6735 CONROY WINDERMERE RD
Practice Address - Street 2:SUITE #202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-3565
Practice Address - Country:US
Practice Address - Phone:407-910-1178
Practice Address - Fax:407-624-3724
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN179231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice