Provider Demographics
NPI:1699751115
Name:FRATTALI, VINCENT JOHN (D D S)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JOHN
Last Name:FRATTALI
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:WELLPINIT
Mailing Address - State:WA
Mailing Address - Zip Code:99040-0357
Mailing Address - Country:US
Mailing Address - Phone:509-258-4517
Mailing Address - Fax:509-258-4456
Practice Address - Street 1:6203 AGENCY LOOP RD
Practice Address - Street 2:
Practice Address - City:WELLPINIT
Practice Address - State:WA
Practice Address - Zip Code:99040-0357
Practice Address - Country:US
Practice Address - Phone:509-258-4517
Practice Address - Fax:509-258-4456
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD078831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice