Healthcare Provider Details

I. General information

NPI: 1700103538
Provider Name (Legal Business Name): FOUNTAIN FAMILY DENTAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 S ALMA SCHOOL RD STE 6
CHANDLER AZ
85248-4510
US

IV. Provider business mailing address

3930 S ALMA SCHOOL RD STE 6
CHANDLER AZ
85248-4510
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-8083
  • Fax: 480-222-8084
Mailing address:
  • Phone: 480-222-8083
  • Fax: 480-222-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6458
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6458
License Number StateAZ

VIII. Authorized Official

Name: DR. ERIC L KERBS
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 480-766-8486