Provider Demographics
NPI:1831640135
Name:RAYMOND A FORTSON JR & ASSOCIATES DDS PC
Entity type:Organization
Organization Name:RAYMOND A FORTSON JR & ASSOCIATES DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-468-4672
Mailing Address - Street 1:27347 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27445 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-3411
Practice Address - Country:US
Practice Address - Phone:248-569-6722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty