MEDICARE: DR. RICHARD FOUNTAIN D.M.D.

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	1223G0001X	General Practice Dentistry	032608	NY

General Provider Information

NPI Number	:	1770799934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD FOUNTAIN D.M.D.

Provider Business Mailing Address
First Line	:	105 LAKE HILL RD
Second Line	:
City	:	BURNT HILLS
State	:	NY
Zip	:	12027-9507
Country	:	US
Telephone Number	:	518-399-4290
Fax Number	:	518-399-5807

Provider Business Practice Location Address
First Line	:	105 LAKE HILL RD
Second Line	:
City	:	BURNT HILLS
State	:	NY
Zip	:	12027-9507
Country	:	US
Telephone Number	:	518-399-4290
Fax Number	:	518-399-5807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	07/08/2007

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