Provider Demographics
NPI:1528187382
Name:FORSLUND, JEFFREY SCOTT
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:FORSLUND
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 1:1575 20TH STREET NORTHWEST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2932
Mailing Address - Country:US
Mailing Address - Phone:507-334-6433
Mailing Address - Fax:507-334-0044
Practice Address - Street 1:1575 20TH STREET NORTHWEST
Practice Address - Street 2:SUITE 102
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2932
Practice Address - Country:US
Practice Address - Phone:507-334-6433
Practice Address - Fax:507-334-0044
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND103231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN325522100Medicaid