Provider Demographics
NPI:1457874588
Name:FANTASEA PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:FANTASEA PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LASTRES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-594-1171
Mailing Address - Street 1:1890 SW HEALTH PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0473
Mailing Address - Country:US
Mailing Address - Phone:239-594-1171
Mailing Address - Fax:
Practice Address - Street 1:1890 SW HEALTH PKWY STE 104
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0473
Practice Address - Country:US
Practice Address - Phone:239-594-1171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN217621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty