Provider Demographics
NPI:1427485259
Name:FORE DENTAL A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:FORE DENTAL A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-273-1470
Mailing Address - Street 1:463 SUTTON WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4102
Mailing Address - Country:US
Mailing Address - Phone:530-273-1470
Mailing Address - Fax:530-272-5409
Practice Address - Street 1:463 SUTTON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4102
Practice Address - Country:US
Practice Address - Phone:530-273-1470
Practice Address - Fax:530-272-5409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40589122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty