Provider Demographics
NPI:1376612838
Name:FORMAN, ROGER J (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
Last Name:FORMAN
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 FOLSOM ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5712
Mailing Address - Country:US
Mailing Address - Phone:303-938-8300
Mailing Address - Fax:303-441-5811
Practice Address - Street 1:1840 FOLSOM ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5712
Practice Address - Country:US
Practice Address - Phone:303-938-8300
Practice Address - Fax:303-441-5811
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist