Provider Demographics
NPI:1083700587
Name:FOUNTAIN, HAROLD WELDON JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:WELDON
Last Name:FOUNTAIN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4385 HUGH HOWELL RD.
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-493-7023
Mailing Address - Fax:770-493-7024
Practice Address - Street 1:4385 HUGH HOWELL RD.
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-493-7023
Practice Address - Fax:770-493-7024
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0081211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice