Provider Demographics
NPI:1518961390
Name:FORSYTH, STEPHEN P (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:P
Last Name:FORSYTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 CLOVER LANE
Mailing Address - Street 2:
Mailing Address - City:MULLETT LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49761-0081
Mailing Address - Country:US
Mailing Address - Phone:231-330-8901
Mailing Address - Fax:
Practice Address - Street 1:545 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2856
Practice Address - Country:US
Practice Address - Phone:920-924-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-175291223G0001X
AZD0082681223G0001X
MI29010130641223G0001X
WI1002044-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice