MEDICARE: DR. SUSAN COPE FORTENBERRY D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	3429-07	MS

General Provider Information

NPI Number	:	1083936132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN COPE FORTENBERRY D.M.D.

Provider Business Mailing Address
First Line	:	5315 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-922-0066
Fax Number	:	601-922-0077

Provider Business Practice Location Address
First Line	:	5315 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-922-0066
Fax Number	:	601-922-0077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2010
Last Update Date	:	02/17/2010

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