Provider Demographics
NPI:1902082910
Name:FONTAINE, DENNIS
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 FAIRGROUNDS MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5362
Mailing Address - Country:US
Mailing Address - Phone:607-277-8126
Mailing Address - Fax:607-277-8613
Practice Address - Street 1:135 FAIRGROUNDS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5362
Practice Address - Country:US
Practice Address - Phone:607-277-8126
Practice Address - Fax:607-277-8613
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist