Healthcare Provider Details

I. General information

NPI: 1740382928
Provider Name (Legal Business Name): DONALD A FANTUZZO DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2196 W SYCAMORE ST
KOKOMO IN
46901
US

IV. Provider business mailing address

2196 W SYCAMORE ST
KOKOMO IN
46901
US

V. Phone/Fax

Practice location:
  • Phone: 765-457-8359
  • Fax: 765-457-9310
Mailing address:
  • Phone: 765-457-8359
  • Fax: 765-457-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12010681A
License Number StateIN

VIII. Authorized Official

Name: DONALD ARDEN FANTUZZO
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 765-457-8359