Provider Demographics
NPI:1740771153
Name:FOMETE, ANNICK M
Entity Type:Individual
Prefix:DR
First Name:ANNICK
Middle Name:M
Last Name:FOMETE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 STATE ROUTE 13 APT 354
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3593
Mailing Address - Country:US
Mailing Address - Phone:240-704-4559
Mailing Address - Fax:
Practice Address - Street 1:1775 GRAND CONCOURSE FL 6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-8202
Practice Address - Country:US
Practice Address - Phone:718-901-8158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist