Provider Demographics
NPI:1104979285
Name:FONFARA, WALTER D (DMD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:D
Last Name:FONFARA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 NORWICH RD
Mailing Address - Street 2:P.O. BOX 71
Mailing Address - City:PLAINFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06374-1734
Mailing Address - Country:US
Mailing Address - Phone:860-564-1689
Mailing Address - Fax:860-564-1848
Practice Address - Street 1:699 NORWICH RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374-1734
Practice Address - Country:US
Practice Address - Phone:860-564-1689
Practice Address - Fax:860-564-1848
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT78411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice