Organization
MARYBETH FASANO DMD PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SHANA D RANDOLPH (INSURANCE/FINANCIAL COORDINATOR)
(757) 412-2235
Entity
Organization
Contact information
Practice address
984 FIRST COLONIAL RD, SUITE 200, VIRGINIA BEACH, VA 23454-3196
(757) 412-2235
(757) 412-2237
Mailing address
984 FIRST COLONIAL RD, SUITE 200, VIRGINIA BEACH, VA 23454-3196
(757) 412-2235
(757) 412-2237
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
0401008908
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
153899
ANTHEM
VA
01
—
980759
UNITED CONCORDIA
VA
Enumeration date
11/13/2007
Last updated
11/13/2007
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