Provider Demographics
NPI:1568555431
Name:FONTANA, MARY E (DDS FACO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:FONTANA
Suffix:
Gender:F
Credentials:DDS FACO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21308 MACK AVENUE
Mailing Address - Street 2:
Mailing Address - City:CROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1047
Mailing Address - Country:US
Mailing Address - Phone:313-881-8080
Mailing Address - Fax:313-881-8088
Practice Address - Street 1:21308 MACK AVENUE
Practice Address - Street 2:
Practice Address - City:CROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1047
Practice Address - Country:US
Practice Address - Phone:313-881-8080
Practice Address - Fax:313-881-8088
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist