Provider Demographics
NPI:1033245196
Name:D.KEITH FORTSON,D.M.D.,P.C.
Entity Type:Organization
Organization Name:D.KEITH FORTSON,D.M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-775-4550
Mailing Address - Street 1:151 S HARKNESS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1832
Mailing Address - Country:US
Mailing Address - Phone:770-775-4550
Mailing Address - Fax:770-775-4338
Practice Address - Street 1:151 S HARKNESS ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1832
Practice Address - Country:US
Practice Address - Phone:770-775-4550
Practice Address - Fax:770-775-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0087641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000136694AMedicaid