Basic Information
| Provider Information | |||||||||
| NPI: | 1134355415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FASULO | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAFONTAINE | ||||||||
| OtherFirstName: | WILLIAM | ||||||||
| OtherMiddleName: | H. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.D.S. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2400 COMPUTER DR | ||||||||
| Address2: | |||||||||
| City: | WESTBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015811887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083292250 | ||||||||
| FaxNumber: | 5083292255 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 COMPUTER DR | ||||||||
| Address2: | |||||||||
| City: | WESTBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015811887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083292250 | ||||||||
| FaxNumber: | 5083292255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2009 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 02096 | NH | N | Dental Providers | Dentist | 1223G0001X | DN1859442 | MA | Y | Dental Providers | Dentist | General Practice |
No ID Information.