Provider Demographics
NPI:1770804429
Name:FASOLI, ADAM (DMD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:FASOLI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 EXCHANGE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-4464
Mailing Address - Country:US
Mailing Address - Phone:802-388-3553
Mailing Address - Fax:802-388-7377
Practice Address - Street 1:1330 EXCHANGE ST STE 107
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-4464
Practice Address - Country:US
Practice Address - Phone:802-388-3553
Practice Address - Fax:802-388-7377
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.00681071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT016.0068107OtherVERMONT STATE LICENSE