Provider Demographics
NPI:1124137419
Name:FAIT, JACLYN M (DDS)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:FAIT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:MARPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3003 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-2689
Mailing Address - Country:US
Mailing Address - Phone:513-732-2277
Mailing Address - Fax:
Practice Address - Street 1:3003 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-2689
Practice Address - Country:US
Practice Address - Phone:513-732-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0223941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2724314Medicaid