Provider Demographics
NPI:1215326830
Name:FABREGA, JUAN C (DMD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:FABREGA
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 1:18134 POWELL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-8141
Mailing Address - Country:US
Mailing Address - Phone:352-848-1050
Mailing Address - Fax:352-848-1094
Practice Address - Street 1:18134 POWELL RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34604-8141
Practice Address - Country:US
Practice Address - Phone:352-848-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist