Healthcare Provider Details

I. General information

NPI: 1184162513
Provider Name (Legal Business Name): FOUNTAIN DENTAL PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8085 FOUNTAIN MESA RD
FOUNTAIN CO
80817-1591
US

IV. Provider business mailing address

8085 FOUNTAIN MESA RD
FOUNTAIN CO
80817-1591
US

V. Phone/Fax

Practice location:
  • Phone: 719-382-5500
  • Fax: 888-790-7062
Mailing address:
  • Phone: 719-382-5500
  • Fax: 888-790-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: SCOTT FREDERICK
Title or Position: OWNER/DOCTOR
Credential: DDS
Phone: 719-382-5500