Provider Demographics
NPI:1043756950
Name:FOUNTAIN, REBECCA (DDS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1249 YORK ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-3082
Mailing Address - Country:US
Mailing Address - Phone:818-425-7510
Mailing Address - Fax:
Practice Address - Street 1:3494 EAGLE BLVD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601
Practice Address - Country:US
Practice Address - Phone:303-659-9543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.002035251223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program