Provider Demographics
NPI:1306258280
Name:FORTSON, CORY
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:FORTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17600 W 12 MILE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1910
Mailing Address - Country:US
Mailing Address - Phone:248-569-6722
Mailing Address - Fax:248-569-7409
Practice Address - Street 1:17600 W 12 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1910
Practice Address - Country:US
Practice Address - Phone:248-569-6722
Practice Address - Fax:248-569-7409
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021215122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist