Provider Demographics
NPI:1922405117
Name:FORTUNATO, PATRICIA ANN LEE (DDS)
Entity Type:Individual
Prefix:
First Name:PATRICIA ANN
Middle Name:LEE
Last Name:FORTUNATO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3396
Mailing Address - Country:US
Mailing Address - Phone:732-376-9333
Mailing Address - Fax:
Practice Address - Street 1:275 HOBART ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861
Practice Address - Country:US
Practice Address - Phone:732-376-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025880001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0470422Medicaid