# MARYBETH FASANO DMD PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194905539
- **Authorized official:** MS. SHANA D RANDOLPH (INSURANCE/FINANCIAL COORDINATOR)
- **Authorized official phone:** (757) 412-2235

## Contact information

- **Practice address:** 984 FIRST COLONIAL RD, SUITE 200, VIRGINIA BEACH, VA 23454-3196
- **Practice address phone:** (757) 412-2235
- **Practice address fax:** (757) 412-2237
- **Mailing address:** 984 FIRST COLONIAL RD, SUITE 200, VIRGINIA BEACH, VA 23454-3196
- **Mailing address phone:** (757) 412-2235
- **Mailing address fax:** (757) 412-2237

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | 0401008908 | VA | Yes |

## Other

- **Enumeration date:** 11/13/2007
- **Last updated:** 11/13/2007