Provider Demographics
NPI:1457527061
Name:FORTGANG, RONALD D (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:D
Last Name:FORTGANG
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 1:16 ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7129
Practice Address - Country:US
Practice Address - Phone:201-664-8647
Practice Address - Fax:201-664-8647
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D100673400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist