Provider Demographics
NPI:1083936132
Name:FORTENBERRY, SUSAN COPE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:COPE
Last Name:FORTENBERRY
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 1:5315 HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-9421
Mailing Address - Country:US
Mailing Address - Phone:601-922-0066
Mailing Address - Fax:601-922-0077
Practice Address - Street 1:5315 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9421
Practice Address - Country:US
Practice Address - Phone:601-922-0066
Practice Address - Fax:601-922-0077
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3429-071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry