Provider Demographics
NPI:1487734281
Name:DEFOREST, DAVID R (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:DEFOREST
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 1:606 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061
Mailing Address - Country:US
Mailing Address - Phone:815-732-3225
Mailing Address - Fax:815-732-3277
Practice Address - Street 1:606 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061
Practice Address - Country:US
Practice Address - Phone:815-732-3225
Practice Address - Fax:815-732-3277
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist