1730434622 NPI number — FOUNTAIN MODERN DENTISTRY AND ORTHODONTICS, LLP

Table of content: (NPI 1730434622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730434622 NPI number — FOUNTAIN MODERN DENTISTRY AND ORTHODONTICS, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN MODERN DENTISTRY AND ORTHODONTICS, LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730434622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6940 MESA RIDGE PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOUNTAIN
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-382-4936
Provider Business Mailing Address Fax Number:
719-382-4938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2860 MICHELLE DRIVE 2ND FLOOR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-368-2077
Provider Business Practice Location Address Fax Number:
714-368-2092
Provider Enumeration Date:
07/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RODGERS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
DDS/ OWNER
Authorized Official Telephone Number:
719-382-4936

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  9356 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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