Provider Demographics
NPI:1962549006
Name:FORTRESS, LAWRENCE N (DDS)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:N
Last Name:FORTRESS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 S. EAST ST.
Mailing Address - Street 2:SUITE F
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2693
Mailing Address - Country:US
Mailing Address - Phone:317-788-4239
Mailing Address - Fax:317-780-0903
Practice Address - Street 1:6904 S. EAST ST.
Practice Address - Street 2:SUITE F
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2693
Practice Address - Country:US
Practice Address - Phone:317-788-4239
Practice Address - Fax:317-780-0903
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN78571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice