Provider Demographics
NPI:1518151760
Name:PHILIP D FANTASIA JR DDS
Entity Type:Organization
Organization Name:PHILIP D FANTASIA JR DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:DOMENIC
Authorized Official - Last Name:FANTASIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-923-9446
Mailing Address - Street 1:293 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1955
Mailing Address - Country:US
Mailing Address - Phone:617-923-9446
Mailing Address - Fax:617-923-4750
Practice Address - Street 1:293 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-1955
Practice Address - Country:US
Practice Address - Phone:617-923-9446
Practice Address - Fax:617-923-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty