Provider Demographics
NPI:1205169182
Name:FORTRESS DENTAL CORPORATION
Entity type:Organization
Organization Name:FORTRESS DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VU
Authorized Official - Middle Name:
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-414-9468
Mailing Address - Street 1:1350 E. CHICAGO ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120
Mailing Address - Country:US
Mailing Address - Phone:847-760-6100
Mailing Address - Fax:847-760-6101
Practice Address - Street 1:1350 E. CHICAGO ST
Practice Address - Street 2:SUITE 4
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120
Practice Address - Country:US
Practice Address - Phone:847-760-6100
Practice Address - Fax:847-760-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190277051223G0001X
IL0190276761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty