Provider Demographics
NPI:1487750154
Name:FOUNTAIN, STEVE EDWARD
Entity type:Individual
Prefix:
First Name:STEVE
Middle Name:EDWARD
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:STEVE
Other - Middle Name:E
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:601 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3512
Mailing Address - Country:US
Mailing Address - Phone:909-625-4101
Mailing Address - Fax:909-625-7973
Practice Address - Street 1:601 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3512
Practice Address - Country:US
Practice Address - Phone:909-625-4101
Practice Address - Fax:909-625-7973
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist