Provider Demographics
NPI:1184730392
Name:FONDAK, JEFFREY THEODORE (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:THEODORE
Last Name:FONDAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33054 NEW YORK STATE ROUTE #26
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-8600
Mailing Address - Country:US
Mailing Address - Phone:315-493-9393
Mailing Address - Fax:315-493-9394
Practice Address - Street 1:33054 STATE ROUTE 26
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-8600
Practice Address - Country:US
Practice Address - Phone:315-493-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332731223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033273OtherDENTAL LICENSE
1342155OtherUNITED CONCORDIA PROVIDER