Provider Demographics
NPI:1487678231
Name:FOURNIER, EDWARD ROBERT JR (DMD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ROBERT
Last Name:FOURNIER
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-1325
Mailing Address - Country:US
Mailing Address - Phone:203-879-2609
Mailing Address - Fax:
Practice Address - Street 1:405 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4924
Practice Address - Country:US
Practice Address - Phone:860-584-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT020005373CT01OtherUNITED HEALTH CARE-DENTAL
CA020005373CT01OtherANTHEM BLUE CROSS