Provider Demographics
NPI:1013285899
Name:FATSE, JOHN G (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:FATSE
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 1:324 ELM ST
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2280
Mailing Address - Country:US
Mailing Address - Phone:203-268-5051
Mailing Address - Fax:203-268-7988
Practice Address - Street 1:324 ELM ST
Practice Address - Street 2:SUITE 202A
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2280
Practice Address - Country:US
Practice Address - Phone:203-268-5051
Practice Address - Fax:203-268-7988
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT71501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice