Provider Demographics
NPI:1275707135
Name:JAMES C. FUSCO, D.D.S., P.C.
Entity Type:Organization
Organization Name:JAMES C. FUSCO, D.D.S., P.C.
Other - Org Name:HERMITAGE DENTAL CENER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:FUSCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-745-2134
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:MO
Mailing Address - Zip Code:65668-0105
Mailing Address - Country:US
Mailing Address - Phone:417-745-2134
Mailing Address - Fax:417-745-2135
Practice Address - Street 1:303 SPRING ST
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:MO
Practice Address - Zip Code:65668-0105
Practice Address - Country:US
Practice Address - Phone:417-745-2134
Practice Address - Fax:417-745-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0155021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO406679209Medicaid
MO187734OtherDORAL DENTAL