Provider Demographics
NPI:1336488469
Name:DEFOREST, DAN HAMPTON (LAC)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:HAMPTON
Last Name:DEFOREST
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH FREEDOM
Mailing Address - State:WI
Mailing Address - Zip Code:53951-9685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORTH FREEDOM
Practice Address - State:WI
Practice Address - Zip Code:53951-9685
Practice Address - Country:US
Practice Address - Phone:608-522-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI146055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist