Provider Demographics
NPI:1982706743
Name:RUSSELL A FORTUNE DDS SC
Entity type:Organization
Organization Name:RUSSELL A FORTUNE DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FORTUNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-782-8834
Mailing Address - Street 1:1600 LOSEY BLVD SOUTH
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6104
Mailing Address - Country:US
Mailing Address - Phone:608-782-8834
Mailing Address - Fax:608-782-5223
Practice Address - Street 1:1600 LOSEY BLVD SOUTH
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6104
Practice Address - Country:US
Practice Address - Phone:608-782-8834
Practice Address - Fax:608-782-5223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2778122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33429900Medicaid