Provider Demographics
NPI:1275925380
Name:FANTUZZO ORAL, MAXILLOFACIAL, AND DENTAL IMPLANT SURGERY, PLLC
Entity Type:Organization
Organization Name:FANTUZZO ORAL, MAXILLOFACIAL, AND DENTAL IMPLANT SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANTUZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS AND MD
Authorized Official - Phone:585-203-1524
Mailing Address - Street 1:1815 CLINTON AVE. SOUTH SUITE 320
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 MAHOGANY RUN
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-9424
Practice Address - Country:US
Practice Address - Phone:585-203-1524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0486041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty