Provider Demographics
NPI:1184162513
Name:FOUNTAIN DENTAL PRACTICE, LLC
Entity type:Organization
Organization Name:FOUNTAIN DENTAL PRACTICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-382-5500
Mailing Address - Street 1:8085 FOUNTAIN MESA RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1591
Mailing Address - Country:US
Mailing Address - Phone:719-382-5500
Mailing Address - Fax:888-790-7062
Practice Address - Street 1:8085 FOUNTAIN MESA RD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1591
Practice Address - Country:US
Practice Address - Phone:719-382-5500
Practice Address - Fax:888-790-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty