Individual
MARYBETH FASANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
984 FIRST COLONIAL RD, SUITE 200, VIRGINIA BEACH, VA 23454
(757) 412-2235
(757) 412-2237
Mailing address
984 FIRST COLONIAL RD, SUITE 200, VIRGINIA BEACH, VA 23454
(757) 412-2235
(757) 412-2237
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
0401008908
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
153899
ANTHEM
—
01
—
980759
UNITED CONCORDIA
—
Enumeration date
07/22/2006
Last updated
07/08/2007
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