Provider Demographics
NPI:1093868713
Name:FONTANA, MICHAEL ROBERT (DMD, PC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:FONTANA
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8791 BARNES LAKE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-3176
Mailing Address - Country:US
Mailing Address - Phone:724-863-5077
Mailing Address - Fax:724-863-9590
Practice Address - Street 1:8791 BARNES LAKE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-3176
Practice Address - Country:US
Practice Address - Phone:724-863-5077
Practice Address - Fax:724-863-9590
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA019730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist