Healthcare Provider Details

I. General information

NPI: 1386995397
Provider Name (Legal Business Name): MATTHEW R. FANTASIA, D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 WASHINGTON ST
WELLESLEY MA
02481-6202
US

IV. Provider business mailing address

372 WASHINGTON ST
WELLESLEY MA
02481-6202
US

V. Phone/Fax

Practice location:
  • Phone: 781-235-1146
  • Fax: 781-235-9195
Mailing address:
  • Phone: 781-235-1146
  • Fax: 781-235-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 20441
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN 14506
License Number StateMA

VIII. Authorized Official

Name: DR. MATTHEW R. FANTASIA
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 781-235-1146