Provider Demographics
NPI:1417009200
Name:FORTENBERRY, WILLIAM COLEMAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:COLEMAN
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:COLE
Other - Middle Name:
Other - Last Name:FORTENBERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:P. O. BOX 1547
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130
Mailing Address - Country:US
Mailing Address - Phone:601-853-3565
Mailing Address - Fax:601-853-3598
Practice Address - Street 1:7731 OLD CANTON RD STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6115
Practice Address - Country:US
Practice Address - Phone:601-853-3565
Practice Address - Fax:601-853-3598
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2543122300000X
MS2543-901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2543OtherDENTAL LICENSE