Provider Demographics
NPI:1245390509
Name:FORSBERG, CLIFTON THEODORE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:THEODORE
Last Name:FORSBERG
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 1:4626 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2007
Mailing Address - Country:US
Mailing Address - Phone:814-864-0684
Mailing Address - Fax:814-864-0685
Practice Address - Street 1:4626 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2007
Practice Address - Country:US
Practice Address - Phone:814-864-0684
Practice Address - Fax:814-864-0685
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022897L1223X0400X
OH30-0174511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics