# FONTAINE DENTAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1558591123
- **Authorized official:** JENNIFER JOY FONTAINE (DDS)
- **Authorized official phone:** (219) 365-7773

## Contact information

- **Practice address:** 9301 WICKER AVE, SAINT JOHN, IN 46373-9403
- **Practice address phone:** (219) 365-7773
- **Practice address fax:** (219) 365-8883
- **Mailing address:** 9301 WICKER AVE, SAINT JOHN, IN 46373-9403
- **Mailing address phone:** (219) 365-7773
- **Mailing address fax:** (219) 365-8883

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 12010668 | IN | Yes |

## Other

- **Enumeration date:** 07/17/2009
- **Last updated:** 07/17/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 12010668 | LICENSE | IN |