Provider Demographics
NPI:1023215654
Name:TAVARES, FATIMA D (DMD)
Entity type:Individual
Prefix:DR
First Name:FATIMA
Middle Name:D
Last Name:TAVARES
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 1:528 SQUANKUM YELLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-3744
Mailing Address - Country:US
Mailing Address - Phone:973-418-9228
Mailing Address - Fax:
Practice Address - Street 1:19048 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2434
Practice Address - Country:US
Practice Address - Phone:813-972-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28829122300000X
NJ22DI02350000122300000X
NJDIO23500001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist