Provider Demographics
NPI:1700103538
Name:FOUNTAIN FAMILY DENTAL CENTER, PLLC
Entity type:Organization
Organization Name:FOUNTAIN FAMILY DENTAL CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:KERBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-766-8486
Mailing Address - Street 1:3930 S ALMA SCHOOL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4510
Mailing Address - Country:US
Mailing Address - Phone:480-222-8083
Mailing Address - Fax:480-222-8084
Practice Address - Street 1:3930 S ALMA SCHOOL RD STE 6
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4510
Practice Address - Country:US
Practice Address - Phone:480-222-8083
Practice Address - Fax:480-222-8084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ64581223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty