Provider Demographics
NPI:1396715165
Name:FORTUNATO, PAUL MICHAEL (DMD, MS, ABGD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:DMD, MS, ABGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PINION DR
Mailing Address - Street 2:10 MEDICAL GROUUP
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-5592
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:10 MEDICAL GROUUP
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice