Provider Demographics
NPI:1699459453
Name:FORKAN, CODY (DMD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:FORKAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 ANAVISTA RD
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2056
Mailing Address - Country:US
Mailing Address - Phone:406-560-6583
Mailing Address - Fax:
Practice Address - Street 1:2425 CORNELL AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-3848
Practice Address - Country:US
Practice Address - Phone:406-494-7919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT259841223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice