Provider Demographics
NPI:1184860850
Name:FANTONI, AMY B (RDH)
Entity Type:Individual
Prefix:MISS
First Name:AMY
Middle Name:B
Last Name:FANTONI
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 W BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2064
Mailing Address - Country:US
Mailing Address - Phone:508-854-7548
Mailing Address - Fax:
Practice Address - Street 1:670 W BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2064
Practice Address - Country:US
Practice Address - Phone:508-854-7548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8559124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071OtherMEDICAID GROUP #