Provider Demographics
NPI:1114386802
Name:FALLAGO, CHRISTOPHER A (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:A
Last Name:FALLAGO
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 1:21 WINDERMERE WAY
Mailing Address - Street 2:
Mailing Address - City:IVORYTON
Mailing Address - State:CT
Mailing Address - Zip Code:06442-1234
Mailing Address - Country:US
Mailing Address - Phone:860-669-4966
Mailing Address - Fax:
Practice Address - Street 1:8 E MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-2058
Practice Address - Country:US
Practice Address - Phone:401-688-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT126681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice