Healthcare Provider Details

I. General information

NPI: 1902980691
Provider Name (Legal Business Name): JUSTINE PAULA IPPOLITO-FATA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JUSTINE P IPPOLITO DDS

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/02/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131-72 40TH ROAD
FLUSHING NY
11354
US

IV. Provider business mailing address

125 WALKER ST FL 2
NEW YORK NY
10013-4135
US

V. Phone/Fax

Practice location:
  • Phone: 718-587-1111
  • Fax: 718-886-3903
Mailing address:
  • Phone: 212-226-8866
  • Fax: 212-226-2289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number043215
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: