Provider Demographics
NPI:1225142649
Name:CLINE-FORTUNATO, CORRINE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORRINE
Middle Name:ANN
Last Name:CLINE-FORTUNATO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 MOUNT HERMON ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066
Mailing Address - Country:US
Mailing Address - Phone:831-430-9910
Mailing Address - Fax:831-440-9914
Practice Address - Street 1:223 MOUNT HERMON ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066
Practice Address - Country:US
Practice Address - Phone:831-430-9910
Practice Address - Fax:831-430-9914
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413791223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1098OtherANESTHESIA LICENSE
CA1098OtherGA PERMIT
CABC4006943OtherDEA
CA1098OtherGA PERMIT