Provider Demographics
NPI:1770572059
Name:KEVIN J FORTIER DDS & THUY T FORTIER DDS INC
Entity type:Organization
Organization Name:KEVIN J FORTIER DDS & THUY T FORTIER DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:THUY
Authorized Official - Middle Name:T
Authorized Official - Last Name:FORTIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-898-8552
Mailing Address - Street 1:408 S BEACH BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1882
Mailing Address - Country:US
Mailing Address - Phone:714-828-8558
Mailing Address - Fax:714-828-8858
Practice Address - Street 1:408 S BEACH BLVD STE 207
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1882
Practice Address - Country:US
Practice Address - Phone:714-828-8558
Practice Address - Fax:714-828-8858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA418801223G0001X
CA418311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty