Provider Demographics
NPI:1073040358
Name:FORRESTER, ROSS LUCAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:LUCAS
Last Name:FORRESTER
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:P.O. BOX 400
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-3551
Mailing Address - Country:US
Mailing Address - Phone:918-448-8399
Mailing Address - Fax:
Practice Address - Street 1:800 W FORREST AVE
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3249
Practice Address - Country:US
Practice Address - Phone:918-448-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0096821223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health