Healthcare Provider Details

I. General information

NPI: 1659377745
Provider Name (Legal Business Name): HIPOLITO FANTAUZZI-ORTIZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CALLE PROGRESO
AGUADILLA PR
00603-5000
US

IV. Provider business mailing address

PO BOX 621
AGUADILLA PR
00605-0621
US

V. Phone/Fax

Practice location:
  • Phone: 787-891-2555
  • Fax: 787-891-2555
Mailing address:
  • Phone: 787-891-2555
  • Fax: 787-891-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0561
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: