Provider Demographics
NPI:1063090587
Name:FORMA DENT PA
Entity type:Organization
Organization Name:FORMA DENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FORERO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-341-0511
Mailing Address - Street 1:5501 N UNIVERSITY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4645
Mailing Address - Country:US
Mailing Address - Phone:954-341-0511
Mailing Address - Fax:
Practice Address - Street 1:5501 N UNIVERSITY DR STE 102
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4645
Practice Address - Country:US
Practice Address - Phone:954-341-0511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty