Provider Demographics
NPI:1487790903
Name:FANTARELLA, DAVID M (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:FANTARELLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 WASHINGTON AVE
Mailing Address - Street 2:2ND FLOOR EAST BUILDING
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1715
Mailing Address - Country:US
Mailing Address - Phone:203-239-1155
Mailing Address - Fax:203-239-2255
Practice Address - Street 1:127 WASHINGTON AVE
Practice Address - Street 2:2ND FLOOR EAST BUILDING
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1715
Practice Address - Country:US
Practice Address - Phone:203-239-1155
Practice Address - Fax:203-239-2255
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT85011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice