Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0700X | Prosthodontist | 30577 | TX |
Y | 1223P0700X | Prosthodontist | DDS65045 | CA |
NPI | 1124419007 |
---|---|
Provider Name | Dr. Christine Ann Fortmann |
First Address | San Juan Capistrano, CA 92675-3784 |
Second Address | San Juan Capistrano, CA 92675-3784 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2015 |
Last Update Date | 16/06/2020 |