Healthcare Provider Details

I. General information

NPI: 1730258286
Provider Name (Legal Business Name): JOHN EDWARD FANTASIA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE LIJMC
NEW HYDE PARK NY
11040-1433
US

IV. Provider business mailing address

27005 76TH AVE LIJMC
NEW HYDE PARK NY
11040-1433
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7116
  • Fax: 718-347-3483
Mailing address:
  • Phone: 718-470-7116
  • Fax: 718-347-3483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number041799-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: