Healthcare Provider Details

I. General information

NPI: 1013094036
Provider Name (Legal Business Name): HARRISON D FORTNEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12630 MONTE VISTA RD STE 205
POWAY CA
92064-2527
US

IV. Provider business mailing address

12630 MONTE VISTA RD STE 205
POWAY CA
92064-2527
US

V. Phone/Fax

Practice location:
  • Phone: 858-485-1290
  • Fax: 858-675-7485
Mailing address:
  • Phone: 858-485-1290
  • Fax: 858-675-7485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number23183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: