Provider Demographics
NPI:1902131428
Name:FONTANILLA, TED R (MT)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:R
Last Name:FONTANILLA
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47-403 AHUIMANU RD
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-4850
Mailing Address - Country:US
Mailing Address - Phone:808-239-9947
Mailing Address - Fax:808-239-2213
Practice Address - Street 1:47-403 AHUIMANU RD
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-4850
Practice Address - Country:US
Practice Address - Phone:808-239-9947
Practice Address - Fax:808-239-2213
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11453174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist