Provider Demographics
NPI:1164520540
Name:FORSBERG, RONALD W (DDS PA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:W
Last Name:FORSBERG
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-9327
Mailing Address - Country:US
Mailing Address - Phone:208-265-4115
Mailing Address - Fax:208-265-2365
Practice Address - Street 1:2005 PINE ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9327
Practice Address - Country:US
Practice Address - Phone:208-265-4115
Practice Address - Fax:208-265-2365
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD17461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000439700Medicaid
ID000010009601OtherREGENCE BLUE SHIELD OF ID
ID67413OtherBLUE CROSS OF IDAHO