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General NPI Number Information
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NPI Number | 1528268869
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Entity Type | Individual
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Provider Name | PHILLIP L FORTNER D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/24/2007
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Last Update Date | 07/24/2007
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Provider Practice Location Address
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Address Line | 569 MCCURDY AVE N
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City | RAINSVILLE
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State | AL
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Zip | 35986-4409
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Country | US
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Telephone | 256-638-7272
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Fax | 256-638-7271
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Provider Business Mailing Address
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Address Line | PO BOX 2119
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City | RAINSVILLE
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State | AL
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Zip | 35986-2119
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Country | US
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Telephone | 256-638-7272
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Fax | 256-638-7271
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4697
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License Number State | AL
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