Provider Demographics
NPI:1194905539
Name:MARYBETH FASANO DMD PC
Entity type:Organization
Organization Name:MARYBETH FASANO DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/FINANCIAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-412-2235
Mailing Address - Street 1:984 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3196
Mailing Address - Country:US
Mailing Address - Phone:757-412-2235
Mailing Address - Fax:757-412-2237
Practice Address - Street 1:984 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3196
Practice Address - Country:US
Practice Address - Phone:757-412-2235
Practice Address - Fax:757-412-2237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008908261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA980759OtherUNITED CONCORDIA
VA153899OtherANTHEM