Provider Demographics
NPI:1376690313
Name:JOHN A FONTAINE DBA PLAZA FAMILY DENTAL
Entity Type:Organization
Organization Name:JOHN A FONTAINE DBA PLAZA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-343-8380
Mailing Address - Street 1:435 MAIN ST
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-8026
Mailing Address - Country:US
Mailing Address - Phone:978-343-8380
Mailing Address - Fax:
Practice Address - Street 1:435 MAIN ST
Practice Address - Street 2:SUITE 2000
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-8026
Practice Address - Country:US
Practice Address - Phone:978-343-8380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty