Justin Riece Fazzolari, DMD, MD

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

065003 Issued in NY

Practice address

200 W 57TH St Ste 804
New York, NY 10019-3217

Phone

(646) 895-9680

NPI assigned

Mar 25, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 15, 2025 through Oct 15, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Carnegie Oral & Maxillofacial Surgery, PLLC

  • Oral and Maxillofacial Surgery Clinic/Center
  • New York, NY
  • NPI 1033580220
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1553472000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1755561600000",
    "number": "1295296168",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 W 57TH ST STE 804",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100193217",
            "telephone_number": "646-895-9680"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 W 57TH ST STE 804",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100193217",
            "telephone_number": "646-895-9680"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FAZZOLARI",
        "first_name": "JUSTIN",
        "middle_name": "RIECE",
        "credential": "DMD, MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-03-25",
        "last_updated": "2025-08-19",
        "certification_date": "2025-08-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NJ",
            "license": "22DI03028700",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NY",
            "license": "065003",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Roberta Fazylova
• Violetta Fazylova
• David A Fazzari, PH.D.
• Dominick M Fazzari, D.C.
• Christina Fazzolare
• FDLC Pediatrics Medicine.PLLC
• Fdny Csu
• Elaina Jean Fealy, PA-C
• Stephen Fealy, MD
• Joseph Fearon

• Oral and Maxillofacial Surgery (Dentist) in New York, NY
• Providers in New York, NY by specialty
• Oral and Maxillofacial Surgery (Dentist) in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.