Provider Demographics
NPI:1164631016
Name:FORREST, GLENN SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:SCOTT
Last Name:FORREST
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 1:707 BROADWAY
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2327
Mailing Address - Country:US
Mailing Address - Phone:516-797-3285
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2327
Practice Address - Country:US
Practice Address - Phone:516-797-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039 055-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice