Provider Demographics
NPI:1316974827
Name:FORTNER, DONALD RICHARD JR (DMD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:RICHARD
Last Name:FORTNER
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 JAKE ALEXANDER BLVD WEST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147
Mailing Address - Country:US
Mailing Address - Phone:704-636-1848
Mailing Address - Fax:704-636-4890
Practice Address - Street 1:1834 JAKE ALEXANDER BLVD WEST
Practice Address - Street 2:SUITE 504
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147
Practice Address - Country:US
Practice Address - Phone:704-636-1848
Practice Address - Fax:704-636-4890
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice