Provider Demographics
NPI:1871600023
Name:FANTASIA, PHILIP DOMINIC JR (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DOMINIC
Last Name:FANTASIA
Suffix:JR
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 1:293 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1955
Mailing Address - Country:US
Mailing Address - Phone:617-923-9446
Mailing Address - Fax:617-923-4250
Practice Address - Street 1:293 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-1955
Practice Address - Country:US
Practice Address - Phone:617-923-9446
Practice Address - Fax:617-923-4250
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice