Provider Demographics
NPI:1376635375
Name:BALE, FORREST GARNETT (DDS)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:GARNETT
Last Name:BALE
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 1:319 S GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-5906
Mailing Address - Country:US
Mailing Address - Phone:479-968-1334
Mailing Address - Fax:
Practice Address - Street 1:319 S GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5906
Practice Address - Country:US
Practice Address - Phone:479-968-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000103701223S0112X
AR37991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery