Healthcare Provider Details

I. General information

NPI: 1083936132
Provider Name (Legal Business Name): SUSAN COPE FORTENBERRY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5315 HIGHWAY 18 W
JACKSON MS
39209-9421
US

IV. Provider business mailing address

5315 HIGHWAY 18 W
JACKSON MS
39209-9421
US

V. Phone/Fax

Practice location:
  • Phone: 601-922-0066
  • Fax: 601-922-0077
Mailing address:
  • Phone: 601-922-0066
  • Fax: 601-922-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3429-07
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: