Provider Demographics
NPI:1083340319
Name:FORTUNE, TATYANA (DMD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8472 SIMMOND ST
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5700
Mailing Address - Country:US
Mailing Address - Phone:301-677-6078
Mailing Address - Fax:
Practice Address - Street 1:8472 SIMMOND ST
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5700
Practice Address - Country:US
Practice Address - Phone:301-677-6078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.0134115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist