Provider Demographics
NPI:1083409098
Name:FONTENOT, MARK GABRIEL (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GABRIEL
Last Name:FONTENOT
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W PINE ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-2913
Mailing Address - Country:US
Mailing Address - Phone:650-799-1456
Mailing Address - Fax:650-887-0324
Practice Address - Street 1:201 W PINE ST STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-2913
Practice Address - Country:US
Practice Address - Phone:650-799-1456
Practice Address - Fax:650-887-0324
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist