MEDICARE: JOHN J FONDER DMD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist
2	1223G0001X	General Practice Dentistry	4514	OK

General Provider Information

NPI Number	:	1134387160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN J FONDER DMD INC

Provider Business Mailing Address
First Line	:	1444 SOUTH NORFOLK AVENUE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74120-5611
Country	:	US
Telephone Number	:	918-747-8802
Fax Number	:	918-584-8805

Provider Business Practice Location Address
First Line	:	1444 SOUTH NORFOLK AVENUE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74120-5611
Country	:	US
Telephone Number	:	918-747-8802
Fax Number	:	918-584-8805

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	DR. JOHN J FONDER
Credential	:	DMD
Telephone Number	:	918-747-8802

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	05/27/2008

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