Provider Demographics
NPI:1063518751
Name:FOUNTAIN, MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 RINGGOLD RD.
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-3905
Mailing Address - Fax:580-442-4002
Practice Address - Street 1:2776 RINGGOLD RD
Practice Address - Street 2:FORT SILL DENTAC
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-6300
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:580-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024267L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice