Provider Demographics
NPI:1578535670
Name:FRATTELLONE, JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FRATTELLONE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 NEWMAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1426
Mailing Address - Country:US
Mailing Address - Phone:732-842-5915
Mailing Address - Fax:732-842-5910
Practice Address - Street 1:515 NEWMAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1426
Practice Address - Country:US
Practice Address - Phone:732-842-5915
Practice Address - Fax:732-842-5910
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ165141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7521502Medicaid
NJ420481Medicare ID - Type Unspecified
NJ7521502Medicaid