Healthcare Provider Details

I. General information

NPI: 1548381288
Provider Name (Legal Business Name): JUANITA MARGO FONSECA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 LAFAYETTE RD BUILDING E
PORTSMOUTH NH
03801-5455
US

IV. Provider business mailing address

278 LAFAYETTE RD BUILDING E
PORTSMOUTH NH
03801-5455
US

V. Phone/Fax

Practice location:
  • Phone: 603-436-7787
  • Fax: 603-436-8597
Mailing address:
  • Phone: 603-436-7787
  • Fax: 603-436-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2654
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: