Provider Demographics
NPI:1578569281
Name:FORT, EDWARD TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:TODD
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 1:8540 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3807
Mailing Address - Country:US
Mailing Address - Phone:310-670-1200
Mailing Address - Fax:310-670-5352
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:310-670-1200
Practice Address - Fax:310-670-5352
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD205231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-3656129OtherFEDERAL TAX ID