MEDICARE: KEVIN J FORTIER DDS & THUY T FORTIER DDS INC

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	41880	CA
2	1223G0001X	General Practice Dentistry	41831	CA

General Provider Information

NPI Number	:	1770572059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN J FORTIER DDS & THUY T FORTIER DDS INC

Provider Business Mailing Address
First Line	:	408 S BEACH BLVD STE 207
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-1882
Country	:	US
Telephone Number	:	714-828-8558
Fax Number	:	714-828-8858

Provider Business Practice Location Address
First Line	:	408 S BEACH BLVD STE 207
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-1882
Country	:	US
Telephone Number	:	714-828-8558
Fax Number	:	714-828-8858

Authorized Official
Title or Position	:	DENTIST OWNER OF CORPORATION
Name	:	THUY T FORTIER
Credential	:	DDS
Telephone Number	:	714-898-8552

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	04/12/2017

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