Basic Information
Provider Information | |||||||||
NPI: | 1801171731 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FONTENOT | ||||||||
FirstName: | FELICIA | ||||||||
MiddleName: | YELENA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FRIZZELL | ||||||||
OtherFirstName: | FELICIA | ||||||||
OtherMiddleName: | YELENA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 649 | ||||||||
Address2: |   | ||||||||
City: | FORT DEFIANCE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865040649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 127 EL PASO ROAD | ||||||||
Address2: |   | ||||||||
City: | RUIDOSO | ||||||||
State: | NM | ||||||||
PostalCode: | 88345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5752579053 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2011 | ||||||||
LastUpdateDate: | 09/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 60898 | CA | N |   | Dental Providers | Dentist |   | 1223G0001X | D4224 | NM | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.