Provider Demographics
NPI:1033440961
Name:WALTER D. FONFARA, D.D.S., P.C.
Entity Type:Organization
Organization Name:WALTER D. FONFARA, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:FONFARA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-564-1689
Mailing Address - Street 1:542 NORWICH RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06374-1725
Mailing Address - Country:US
Mailing Address - Phone:860-564-1689
Mailing Address - Fax:860-564-1848
Practice Address - Street 1:542 NORWICH RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374-1725
Practice Address - Country:US
Practice Address - Phone:860-564-1689
Practice Address - Fax:860-564-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty