Provider Demographics
NPI:1346793163
Name:FANELLI, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FANELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MILL ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1015
Mailing Address - Country:US
Mailing Address - Phone:610-223-7777
Mailing Address - Fax:
Practice Address - Street 1:555 MILL ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1015
Practice Address - Country:US
Practice Address - Phone:610-223-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0409881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics