Provider Demographics
NPI:1902980691
Name:IPPOLITO-FATA, JUSTINE PAULA (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:PAULA
Last Name:IPPOLITO-FATA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JUSTINE
Other - Middle Name:P
Other - Last Name:IPPOLITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:125 WALKER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4135
Mailing Address - Country:US
Mailing Address - Phone:212-226-8866
Mailing Address - Fax:212-226-2289
Practice Address - Street 1:131-72 40TH ROAD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-587-1111
Practice Address - Fax:718-886-3903
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02259254Medicaid