MEDICARE: DR. DONALD RICHARD FORTNER JR. DMD

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	1223G0001X	General Practice Dentistry	5908	NC

General Provider Information

NPI Number	:	1316974827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD RICHARD FORTNER JR. DMD

Provider Business Mailing Address
First Line	:	1834 JAKE ALEXANDER BLVD WEST
Second Line	:	SUITE 504
City	:	SALISBURY
State	:	NC
Zip	:	28147
Country	:	US
Telephone Number	:	704-636-1848
Fax Number	:	704-636-4890

Provider Business Practice Location Address
First Line	:	1834 JAKE ALEXANDER BLVD WEST
Second Line	:	SUITE 504
City	:	SALISBURY
State	:	NC
Zip	:	28147
Country	:	US
Telephone Number	:	704-636-1848
Fax Number	:	704-636-4890

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	02/09/2009

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