Provider Demographics
NPI:1740382928
Name:DONALD A FANTUZZO DDS PC
Entity Type:Organization
Organization Name:DONALD A FANTUZZO DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ARDEN
Authorized Official - Last Name:FANTUZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-457-8359
Mailing Address - Street 1:2196 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901
Mailing Address - Country:US
Mailing Address - Phone:765-457-8359
Mailing Address - Fax:765-457-9310
Practice Address - Street 1:2196 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901
Practice Address - Country:US
Practice Address - Phone:765-457-8359
Practice Address - Fax:765-457-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010681A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty