Provider Demographics
NPI:1891970166
Name:JERALYN R. FANTARELLA, DMD, P.C.
Entity Type:Organization
Organization Name:JERALYN R. FANTARELLA, DMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERALYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FANTARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-288-4855
Mailing Address - Street 1:299 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3026
Mailing Address - Country:US
Mailing Address - Phone:203-288-4855
Mailing Address - Fax:203-288-9812
Practice Address - Street 1:299 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3026
Practice Address - Country:US
Practice Address - Phone:203-288-4855
Practice Address - Fax:203-288-9812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT76131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty