Provider Demographics
NPI:1144234725
Name:FORT, CHARLES MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARK
Last Name:FORT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 E BYERS AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7558
Mailing Address - Country:US
Mailing Address - Phone:270-926-3838
Mailing Address - Fax:270-926-0452
Practice Address - Street 1:1208 E BYERS AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7558
Practice Address - Country:US
Practice Address - Phone:270-926-3838
Practice Address - Fax:270-926-0452
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056025Medicaid