Healthcare Provider Details

I. General information

NPI: 1386182277
Provider Name (Legal Business Name): CRISTA FANTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 TOWNE AVE
PLAINFIELD VT
05667
US

IV. Provider business mailing address

PO BOX 320
PLAINFIELD VT
05667-0320
US

V. Phone/Fax

Practice location:
  • Phone: 802-454-8336
  • Fax: 802-454-8339
Mailing address:
  • Phone: 802-454-8336
  • Fax: 802-454-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0160133869
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: