Provider Demographics
NPI:1528106986
Name:FAYANS, EDGAR P (DDS)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:P
Last Name:FAYANS
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 1:255 SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-3342
Mailing Address - Country:US
Mailing Address - Phone:516-763-4996
Mailing Address - Fax:
Practice Address - Street 1:255 SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-3342
Practice Address - Country:US
Practice Address - Phone:516-763-4996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00948132Medicaid
NY00948132Medicaid