Provider Demographics
NPI:1417141151
Name:FORMAN, BETH SANDRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:SANDRA
Last Name:FORMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 ENCINITAS BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3761
Mailing Address - Country:US
Mailing Address - Phone:760-436-1542
Mailing Address - Fax:760-436-1430
Practice Address - Street 1:679 ENCINITAS BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3761
Practice Address - Country:US
Practice Address - Phone:760-436-1542
Practice Address - Fax:760-436-1430
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist