Provider Demographics
NPI:1871231399
Name:FOUNTAIN VIEW FAMILY DENTAL
Entity Type:Organization
Organization Name:FOUNTAIN VIEW FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-799-1110
Mailing Address - Street 1:925 EAST PONTALUNA ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444
Mailing Address - Country:US
Mailing Address - Phone:231-799-1110
Mailing Address - Fax:231-799-1109
Practice Address - Street 1:925 EAST PONTALUNA ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-799-1110
Practice Address - Fax:231-799-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI015602OtherSTATE LICENSE NUMBER