Provider Demographics
NPI:1548607765
Name:FORTSON, DENNIS KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:KEITH
Last Name:FORTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S HARKNESS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1832
Mailing Address - Country:US
Mailing Address - Phone:770-775-4550
Mailing Address - Fax:770-775-4338
Practice Address - Street 1:151 S HARKNESS ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1832
Practice Address - Country:US
Practice Address - Phone:770-775-4550
Practice Address - Fax:770-775-4338
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000136694AMedicaid