Provider Demographics
NPI:1073688792
Name:FORTMAN, EUGENE JOHN
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:JOHN
Last Name:FORTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 HAWK HILL LN. SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902
Mailing Address - Country:US
Mailing Address - Phone:507-288-1073
Mailing Address - Fax:
Practice Address - Street 1:1010 4TH ST SW STE 300
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2856
Practice Address - Country:US
Practice Address - Phone:641-424-0301
Practice Address - Fax:641-424-0301
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN077461223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics