Provider Demographics
NPI:1457474850
Name:FONNESBECK, VANCE B (DDS)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:B
Last Name:FONNESBECK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 E 100 N
Mailing Address - Street 2:SUITE #3
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2640
Mailing Address - Country:US
Mailing Address - Phone:435-637-5850
Mailing Address - Fax:435-637-5151
Practice Address - Street 1:590 E 100 N
Practice Address - Street 2:SUITE #3
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2640
Practice Address - Country:US
Practice Address - Phone:435-637-5850
Practice Address - Fax:435-637-5151
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142950-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice