Provider Demographics
NPI:1902980691
Name:IPPOLITO-FATA, JUSTINE PAULA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:PAULA
Last Name:IPPOLITO-FATA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JUSTINE
Other - Middle Name:P
Other - Last Name:IPPOLITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2466 ARTHUR AVE.
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458
Mailing Address - Country:US
Mailing Address - Phone:718-329-1000
Mailing Address - Fax:718-329-2607
Practice Address - Street 1:2466 ARTHUR AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458
Practice Address - Country:US
Practice Address - Phone:718-329-1000
Practice Address - Fax:718-329-2607
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043215OtherNY STATE LICENSE NUMBER