Provider Demographics
NPI:1477755924
Name:FANTARELLA, JERALYN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERALYN
Middle Name:R
Last Name:FANTARELLA
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 1:299 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3026
Mailing Address - Country:US
Mailing Address - Phone:203-288-4855
Mailing Address - Fax:203-288-9812
Practice Address - Street 1:299 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3026
Practice Address - Country:US
Practice Address - Phone:203-288-4855
Practice Address - Fax:203-288-9812
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT76131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice