Basic Information
| Provider Information | |||||||||
| NPI: | 1730434622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNTAIN MODERN DENTISTRY AND ORTHODONTICS, LLP | ||||||||
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| OtherOrganizationName: | FOUNTAIN MODERN DENTISTRY AND ORTHODONTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6940 MESA RIDGE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193824936 | ||||||||
| FaxNumber: | 7193824938 | ||||||||
| Practice Location | |||||||||
| Address1: | 2860 MICHELLE DRIVE 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143682077 | ||||||||
| FaxNumber: | 7143682092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | RODGERS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | DDS/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7193824936 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9356 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.