Provider Demographics
NPI:1720335003
Name:FASCIANI, DEAN (OD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:FASCIANI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:DEAN
Other - Middle Name:
Other - Last Name:HAURYLUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:602-528-1255
Practice Address - Street 1:483 W. SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-0038
Practice Address - Country:US
Practice Address - Phone:602-528-1200
Practice Address - Fax:602-528-1255
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
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AZZ164075Medicare PIN
AZZ162077Medicare PIN
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AZZ162079Medicare PIN
AZZ164076Medicare PIN