Provider Demographics
NPI:1508082421
Name:M. BRAD FORREST & STACY OLLER FORREST, DMD, PA
Entity Type:Organization
Organization Name:M. BRAD FORREST & STACY OLLER FORREST, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:BRAD
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-882-1113
Mailing Address - Street 1:7900 STEVENS MILL ROAD
Mailing Address - Street 2:STE I
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-2929
Mailing Address - Country:US
Mailing Address - Phone:704-882-1113
Mailing Address - Fax:704-882-3711
Practice Address - Street 1:7900 STEVENS MILL ROAD
Practice Address - Street 2:STE I
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-2929
Practice Address - Country:US
Practice Address - Phone:704-882-1113
Practice Address - Fax:704-882-3711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC67631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty