Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 3429-07 | MS |
NPI | 1083936132 |
---|---|
Provider Name | Dr. Susan Cope Fortenberry |
First Address | Jackson, MS 39209-9421 |
Second Address | Jackson, MS 39209-9421 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2010 |
Last Update Date | 17/02/2010 |