Provider Demographics
NPI:1447395793
Name:DANTONIO, THERESA
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:DANTONIO
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:DANTONIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:82 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2134
Mailing Address - Country:US
Mailing Address - Phone:848-222-1003
Mailing Address - Fax:848-299-4512
Practice Address - Street 1:82 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2134
Practice Address - Country:US
Practice Address - Phone:848-222-1003
Practice Address - Fax:848-299-4512
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01944100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7024801Medicaid