MEDICARE: DR. HARRY H FONTEYNE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1916576	IL

General Provider Information

NPI Number	:	1669485892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARRY H FONTEYNE DDS

Provider Business Mailing Address
First Line	:	748 GREEN PARK AVE
Second Line	:
City	:	COLONA
State	:	IL
Zip	:	61241-9617
Country	:	US
Telephone Number	:	309-792-2211
Fax Number	:	309-792-4678

Provider Business Practice Location Address
First Line	:	748 GREEN PARK AVE
Second Line	:
City	:	COLONA
State	:	IL
Zip	:	61241-9617
Country	:	US
Telephone Number	:	309-792-2211
Fax Number	:	309-792-4678

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	07/08/2007

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