Provider Demographics
NPI:1962182840
Name:FONTAINE, COLETTE LEE
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:LEE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W 5TH AVE APT 407
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2036
Mailing Address - Country:US
Mailing Address - Phone:650-264-9164
Mailing Address - Fax:
Practice Address - Street 1:85 W 5TH AVE APT 407
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2036
Practice Address - Country:US
Practice Address - Phone:650-520-0396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP949124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist