Provider Demographics
NPI:1679613335
Name:FAGIOLETTI, LISA A (DMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:FAGIOLETTI
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 1:25 W COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1463
Mailing Address - Country:US
Mailing Address - Phone:302-514-9064
Mailing Address - Fax:302-514-9071
Practice Address - Street 1:25 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1463
Practice Address - Country:US
Practice Address - Phone:302-514-9064
Practice Address - Fax:302-514-9071
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG10001153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000037168Medicaid