Provider Demographics
NPI:1073620373
Name:FANTUZZO, JOSEPH J (DDS, MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:FANTUZZO
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 705
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-5084
Mailing Address - Fax:585-276-0293
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 705
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-5084
Practice Address - Fax:585-276-0293
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0436041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ123OtherPREFERRED CARE
NY02636886Medicaid
I26293Medicare UPIN
RA5992Medicare ID - Type Unspecified