Individual
AUDREY LEE FORTIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
989 ELLIS AVE, JACKSON, MS 39209-6256
(769) 235-3919
Mailing address
649 MUIRWOOD CIR, RIDGELAND, MS 39157-3623
(662) 560-7211
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
4289-22
MS
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/12/2021
Last updated
07/07/2022
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