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General NPI Number Information
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NPI Number | 1760552491
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Entity Type | Organization
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Legal Business Name | FOUNTAIN DENTAL CENTER, PC
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 320 S SANTA FE AVE
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City | FOUNTAIN
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State | CO
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Zip | 80817-1963
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Country | US
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Telephone | 719-382-5500
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Fax | 719-382-0944
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Provider Business Mailing Address
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Address Line | 320 S SANTA FE AVE
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City | FOUNTAIN
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State | CO
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Zip | 80817-1963
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Country | US
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Telephone | 719-382-5500
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Fax | 719-382-0944
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Authorized Official
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Title or Position | DENTIST
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Name | DR. GLENN ANTHONY NOBLE
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Credential | DDS
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Telephone | 719-382-5500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7581
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License Number State | CO
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