Provider Demographics
NPI:1568742021
Name:FORTSON, RALPH WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:WAYNE
Last Name:FORTSON
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 1:10549 N FLORIDA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6707
Mailing Address - Country:US
Mailing Address - Phone:813-935-3129
Mailing Address - Fax:813-933-0923
Practice Address - Street 1:10549 N FLORIDA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6707
Practice Address - Country:US
Practice Address - Phone:813-935-3129
Practice Address - Fax:813-933-0923
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice