Provider Demographics
NPI:1558591123
Name:FONTAINE DENTAL GROUP
Entity Type:Organization
Organization Name:FONTAINE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-365-7773
Mailing Address - Street 1:9301 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9403
Mailing Address - Country:US
Mailing Address - Phone:219-365-7773
Mailing Address - Fax:219-365-8883
Practice Address - Street 1:9301 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9403
Practice Address - Country:US
Practice Address - Phone:219-365-7773
Practice Address - Fax:219-365-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12010668OtherLICENSE