Healthcare Provider Details

I. General information

NPI: 1275684797
Provider Name (Legal Business Name): FOUNTAIN OAKS DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3763 ROSWELL RD NE
ATLANTA GA
30342-4414
US

IV. Provider business mailing address

4920 ROSWELL RD NE STE 13A
ATLANTA GA
30342-2636
US

V. Phone/Fax

Practice location:
  • Phone: 404-261-2211
  • Fax: 404-261-1390
Mailing address:
  • Phone: 404-261-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM ANDREW LITTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 678-879-1177