Provider Demographics
NPI:1760552491
Name:FOUNTAIN DENTAL CENTER, PC
Entity Type:Organization
Organization Name:FOUNTAIN DENTAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-382-5500
Mailing Address - Street 1:320 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1963
Mailing Address - Country:US
Mailing Address - Phone:719-382-5500
Mailing Address - Fax:719-382-0944
Practice Address - Street 1:320 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1963
Practice Address - Country:US
Practice Address - Phone:719-382-5500
Practice Address - Fax:719-382-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO75811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty