Provider Demographics
NPI:1962894683
Name:DE FAZIO, MICHELLE (DDS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DE FAZIO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 SALZEDO ST APT 418
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4337
Mailing Address - Country:US
Mailing Address - Phone:954-770-1666
Mailing Address - Fax:651-523-8584
Practice Address - Street 1:1 ALHAMBRA PLZ STE 25
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5216
Practice Address - Country:US
Practice Address - Phone:786-507-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13646122300000X
FLDN21777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist