Individual
DR. JEFFREY THEODORE FONDAK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Taxonomy
Speciality
Code
Description
License number
State
1223P0700X
Prosthodontics
Primary
033273
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
033273
DENTAL LICENSE
NY
01
—
1342155
UNITED CONCORDIA PROVIDER
—
Enumeration date
08/21/2006
Last updated
07/08/2007
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