Provider Demographics
NPI:1467144527
Name:FORTIN, ALLEN J (LD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:J
Last Name:FORTIN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 CARRIAGE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-2412
Mailing Address - Country:US
Mailing Address - Phone:207-667-6222
Mailing Address - Fax:207-412-0015
Practice Address - Street 1:403 WILSON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1521
Practice Address - Country:US
Practice Address - Phone:207-667-6222
Practice Address - Fax:207-412-0015
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDTR5543122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist