Healthcare Provider Details

I. General information

NPI: 1679264972
Provider Name (Legal Business Name): DANIEL FORREST FONTENOT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23678 US HIGHWAY 98
FAIRHOPE AL
36532-3336
US

IV. Provider business mailing address

1919 7TH AVE S
BIRMINGHAM AL
35233-2005
US

V. Phone/Fax

Practice location:
  • Phone: 251-928-8770
  • Fax:
Mailing address:
  • Phone: 205-934-3387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD.007324-C1
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: