1902980691 NPI number — DR. JUSTINE PAULA IPPOLITO-FATA DDS.

Table of content: DR. JUSTINE PAULA IPPOLITO-FATA DDS. (NPI 1902980691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902980691 NPI number — DR. JUSTINE PAULA IPPOLITO-FATA DDS.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IPPOLITO-FATA
Provider First Name:
JUSTINE
Provider Middle Name:
PAULA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IPPOLITO
Provider Other First Name:
JUSTINE
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902980691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2466 ARTHUR AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-329-1000
Provider Business Mailing Address Fax Number:
718-329-2607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2466 ARTHUR AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-329-1000
Provider Business Practice Location Address Fax Number:
718-329-2607
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  043215 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 043215 . This is a "NY STATE LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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