Provider Demographics
NPI:1831211648
Name:FANTI, JENNIFER SOPHIA (BS DDS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SOPHIA
Last Name:FANTI
Suffix:
Gender:F
Credentials:BS DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13115 ARGYLE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195
Mailing Address - Country:US
Mailing Address - Phone:734-283-4945
Mailing Address - Fax:
Practice Address - Street 1:24459 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:734-946-8620
Practice Address - Fax:734-946-6272
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018627122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist