Provider Demographics
NPI:1437411493
Name:FOUTZ, JONAH LEROY
Entity Type:Individual
Prefix:DR
First Name:JONAH
Middle Name:LEROY
Last Name:FOUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 CALLE ALEGRIA NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1368
Mailing Address - Country:US
Mailing Address - Phone:816-550-8494
Mailing Address - Fax:
Practice Address - Street 1:5901 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3838
Practice Address - Country:US
Practice Address - Phone:505-821-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD36621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice