Provider Demographics
NPI:1447469879
Name:JOHN W FAUL, DMD, PA
Entity type:Organization
Organization Name:JOHN W FAUL, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-626-7725
Mailing Address - Street 1:140 SW GROVE ST
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-9526
Mailing Address - Country:US
Mailing Address - Phone:321-626-7725
Mailing Address - Fax:
Practice Address - Street 1:7435 STATE ROAD 21
Practice Address - Street 2:SUITE B
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9301
Practice Address - Country:US
Practice Address - Phone:352-473-8988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN08155261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental