Provider Demographics
NPI:1902588528
Name:FOUNTAIN, JESSICA MINDY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MINDY
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 GA HIGHWAY 56 N
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-7022
Mailing Address - Country:US
Mailing Address - Phone:770-601-7421
Mailing Address - Fax:
Practice Address - Street 1:328 MARGIE DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8933
Practice Address - Country:US
Practice Address - Phone:478-971-7701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1232151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice