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General NPI Number Information
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NPI Number | 1891970166
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Entity Type | Organization
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Legal Business Name | JERALYN R. FANTARELLA, DMD, P.C.
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Dates
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Enumeration Date | 01/07/2008
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Last Update Date | 01/07/2008
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Provider Practice Location Address
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Address Line | 299 WASHINGTON AVE
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City | HAMDEN
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State | CT
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Zip | 06518-3026
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Country | US
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Telephone | 203-288-4855
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Fax | 203-288-9812
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Provider Business Mailing Address
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Address Line | 299 WASHINGTON AVE
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City | HAMDEN
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State | CT
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Zip | 06518-3026
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Country | US
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Telephone | 203-288-4855
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Fax | 203-288-9812
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERALYN R FANTARELLA
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Credential | DMD
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Telephone | 203-288-4855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7613
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License Number State | CT
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