Provider Demographics
NPI:1396830741
Name:FORT, KENYON MCGILL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENYON
Middle Name:MCGILL
Last Name:FORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7135 DR. M. L. KING JR., STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702
Mailing Address - Country:US
Mailing Address - Phone:727-525-5455
Mailing Address - Fax:727-525-7223
Practice Address - Street 1:7135 DR. M. L. KING JR., STREET NORTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-525-5455
Practice Address - Fax:727-525-7223
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00124961223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL69983Medicare ID - Type Unspecified
FLU55707Medicare UPIN