Provider Demographics
NPI:1053141382
Name:FORTIN DENTURE CLINIC LLC
Entity type:Organization
Organization Name:FORTIN DENTURE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:207-341-0968
Mailing Address - Street 1:4 N CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-3335
Mailing Address - Country:US
Mailing Address - Phone:207-341-0968
Mailing Address - Fax:
Practice Address - Street 1:2689 N BELFAST AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-0204
Practice Address - Country:US
Practice Address - Phone:207-341-0968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty