Provider Demographics
NPI:1497726590
Name:FORESTAL, EDMISE (DDS)
Entity Type:Individual
Prefix:
First Name:EDMISE
Middle Name:
Last Name:FORESTAL
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 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-583-1800
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4748
Practice Address - Country:US
Practice Address - Phone:518-464-0402
Practice Address - Fax:518-464-0409
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0522781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9184483OtherDORAL
NY02772094Medicaid
NY10115236OtherCDPHP