Provider Demographics
NPI:1619010873
Name:FANTACONE, CYNTHIA (DDS)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:
Last Name:FANTACONE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 BAYVIEW TER
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2495
Mailing Address - Country:US
Mailing Address - Phone:415-388-2461
Mailing Address - Fax:
Practice Address - Street 1:60 BAYVIEW TER
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2495
Practice Address - Country:US
Practice Address - Phone:415-388-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29266122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist