Provider Demographics
NPI:1235653031
Name:FOUNTAIN INN DENTAL, LLC
Entity Type:Organization
Organization Name:FOUNTAIN INN DENTAL, LLC
Other - Org Name:FOUNTAIN INN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIKAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-877-4110
Mailing Address - Street 1:1125 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-1322
Mailing Address - Country:US
Mailing Address - Phone:864-409-7733
Mailing Address - Fax:
Practice Address - Street 1:1125 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1322
Practice Address - Country:US
Practice Address - Phone:864-409-7733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty