Provider Demographics
NPI:1801372008
Name:FAZZIO, JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:FAZZIO
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 1:519 ADA DR SE STE A
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9069
Mailing Address - Country:US
Mailing Address - Phone:616-676-9177
Mailing Address - Fax:
Practice Address - Street 1:519 ADA DR SE STE A
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9069
Practice Address - Country:US
Practice Address - Phone:616-676-9177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist