Provider Demographics
NPI:1467130757
Name:FANSIWALA, NATASHA K (DMD)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:K
Last Name:FANSIWALA
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 NUTFIELD CT APT 33
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2623
Mailing Address - Country:US
Mailing Address - Phone:518-879-9621
Mailing Address - Fax:
Practice Address - Street 1:61 NH 27
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:NH
Practice Address - Zip Code:03077-1273
Practice Address - Country:US
Practice Address - Phone:603-895-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist