Provider Demographics
NPI:1497332126
Name:FUSCO, ANTHONY JOE (DMD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOE
Last Name:FUSCO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3463 US-21
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715
Mailing Address - Country:US
Mailing Address - Phone:704-825-2081
Mailing Address - Fax:
Practice Address - Street 1:3463 US-21
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715
Practice Address - Country:US
Practice Address - Phone:704-825-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61295237122300000X
390200000X
SC107021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program