Provider Demographics
NPI:1346371630
Name:FORTE, JACQUELINE NICOLE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:FORTE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E ASH LN
Mailing Address - Street 2:#14305
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-4698
Mailing Address - Country:US
Mailing Address - Phone:817-545-4059
Mailing Address - Fax:
Practice Address - Street 1:200 EAST STATE HWY 114
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:817-567-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13113124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist