Provider Demographics
NPI:1861594061
Name:FANTUZZO, DONALD A (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:FANTUZZO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6414 LITTLE FLOCK RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IN
Mailing Address - Zip Code:47460-5889
Mailing Address - Country:US
Mailing Address - Phone:812-876-4179
Mailing Address - Fax:
Practice Address - Street 1:1690 S OHIO ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-3317
Practice Address - Country:US
Practice Address - Phone:765-342-8435
Practice Address - Fax:765-457-9310
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010681A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice