Provider Demographics
NPI:1275798753
Name:FALLON, ANDREA (DMD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:FALLON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SOUTH END BRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001
Mailing Address - Country:US
Mailing Address - Phone:413-786-0085
Mailing Address - Fax:413-786-0025
Practice Address - Street 1:1 SOUTH END BRIDGE CIR
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001
Practice Address - Country:US
Practice Address - Phone:413-786-0085
Practice Address - Fax:413-786-0025
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice