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General NPI Number Information
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NPI Number | 1184730392
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Entity Type | Individual
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Provider Name | JEFFREY THEODORE FONDAK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 33054 STATE ROUTE 26
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City | CARTHAGE
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State | NY
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Zip | 13619-8600
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Country | US
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Telephone | 315-493-2106
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Fax |
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Provider Business Mailing Address
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Address Line | 33054 NEW YORK STATE ROUTE #26
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City | CARTHAGE
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State | NY
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Zip | 13619-8600
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Country | US
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Telephone | 315-493-9393
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Fax | 315-493-9394
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 033273
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License Number State | NY
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