Provider Demographics
NPI:1114102076
Name:DELFORGE, DREW J, (DDS)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:J,
Last Name:DELFORGE
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 1:2727 6TH STREET
Mailing Address - Street 2:P.O. BOX 399
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-0399
Mailing Address - Country:US
Mailing Address - Phone:608-325-4995
Mailing Address - Fax:
Practice Address - Street 1:2727 6TH STREET
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-0399
Practice Address - Country:US
Practice Address - Phone:608-325-4995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33659800Medicaid