Provider Demographics
NPI:1558983296
Name:FORTUNO, MASON CLEARY DITTHARDT (DMD)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:CLEARY DITTHARDT
Last Name:FORTUNO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN250011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice