Provider Demographics
NPI:1841373560
Name:FORTENBERRY, LINDA MALMSTROM (DMD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:MALMSTROM
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1459
Mailing Address - Street 2:
Mailing Address - City:EAST DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02641-1459
Mailing Address - Country:US
Mailing Address - Phone:508-385-3004
Mailing Address - Fax:508-385-2412
Practice Address - Street 1:1335 ROUTE 134
Practice Address - Street 2:
Practice Address - City:EAST DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02641
Practice Address - Country:US
Practice Address - Phone:508-385-3004
Practice Address - Fax:508-385-2412
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0151061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice