Provider Demographics
NPI:1225310022
Name:GEARHART, FORREST RUSSELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:FORREST
Middle Name:RUSSELL
Last Name:GEARHART
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 1:3851 LAKEWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6282
Mailing Address - Country:US
Mailing Address - Phone:216-315-4760
Mailing Address - Fax:
Practice Address - Street 1:3406 ALDER AVE
Practice Address - Street 2:
Practice Address - City:FT. WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:907-353-2917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-43741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice