Provider Demographics
NPI:1902834005
Name:FOUNTAIN, ANITA C (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:C
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 E LAMAR RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-3247
Mailing Address - Country:US
Mailing Address - Phone:480-584-5212
Mailing Address - Fax:
Practice Address - Street 1:14122 W MCDOWELL RD
Practice Address - Street 2:STE. 200
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2503
Practice Address - Country:US
Practice Address - Phone:623-536-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD21791223G0001X
WI2413-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice