Provider Demographics
NPI:1275684797
Name:FOUNTAIN OAKS DENTAL P.C.
Entity Type:Organization
Organization Name:FOUNTAIN OAKS DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:LITTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-879-1177
Mailing Address - Street 1:4920 ROSWELL RD NE STE 13A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2636
Mailing Address - Country:US
Mailing Address - Phone:404-261-2211
Mailing Address - Fax:
Practice Address - Street 1:3763 ROSWELL RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4414
Practice Address - Country:US
Practice Address - Phone:404-261-2211
Practice Address - Fax:404-261-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service