Provider Demographics
NPI:1699905620
Name:FAZILI, SNOWBER (DMD)
Entity type:Individual
Prefix:
First Name:SNOWBER
Middle Name:
Last Name:FAZILI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 WEST MAIN
Mailing Address - Street 2:SUITE# 203
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3038
Mailing Address - Country:US
Mailing Address - Phone:617-872-4125
Mailing Address - Fax:
Practice Address - Street 1:7210 W MAIN ST
Practice Address - Street 2:SUITE# 203
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3038
Practice Address - Country:US
Practice Address - Phone:617-872-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0279801223G0001X
MO20080356561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice