Provider Demographics
NPI:1134355415
Name:FASULO, JEFFREY N (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:N
Last Name:FASULO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:H
Other - Last Name:LAFONTAINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2400 COMPUTER DR
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-1887
Mailing Address - Country:US
Mailing Address - Phone:508-329-2250
Mailing Address - Fax:508-329-2255
Practice Address - Street 1:2400 COMPUTER DR
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1887
Practice Address - Country:US
Practice Address - Phone:508-329-2250
Practice Address - Fax:508-329-2255
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02096122300000X
MADN18594421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist