Healthcare Provider Details

I. General information

NPI: 1073620373
Provider Name (Legal Business Name): JOSEPH J FANTUZZO D.D.S, M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 705
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 705
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5084
  • Fax: 585-276-0293
Mailing address:
  • Phone: 585-275-5084
  • Fax: 585-276-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number043604
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: