Provider Demographics
NPI:1710672373
Name:BORTNEM, ERIC ARDEEN (DMD, MS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ARDEEN
Last Name:BORTNEM
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 ECHO POINT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1140
Mailing Address - Country:US
Mailing Address - Phone:605-999-1619
Mailing Address - Fax:
Practice Address - Street 1:809 SW ALSBURY BLVD # 100
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-9200
Practice Address - Country:US
Practice Address - Phone:817-426-1406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX386971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics