Provider Demographics
NPI:1659377745
Name:FANTAUZZI-ORTIZ, HIPOLITO (DMD)
Entity Type:Individual
Prefix:DR
First Name:HIPOLITO
Middle Name:
Last Name:FANTAUZZI-ORTIZ
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:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-0621
Mailing Address - Country:US
Mailing Address - Phone:787-891-2555
Mailing Address - Fax:787-891-2555
Practice Address - Street 1:2 CALLE PROGRESO
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5000
Practice Address - Country:US
Practice Address - Phone:787-891-2555
Practice Address - Fax:787-891-2555
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR05611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice