Provider Demographics
NPI:1518148188
Name:FORMAN, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:FORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516
Mailing Address - Country:US
Mailing Address - Phone:203-932-5818
Mailing Address - Fax:203-933-6432
Practice Address - Street 1:655 SAWMILL RD
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-932-5818
Practice Address - Fax:203-933-6432
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT36451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice