Provider Demographics
NPI:1568831493
Name:RUSSELL L FORMAN, DMD, PC
Entity Type:Organization
Organization Name:RUSSELL L FORMAN, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:LANG
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-868-5500
Mailing Address - Street 1:875 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 63
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3067
Mailing Address - Country:US
Mailing Address - Phone:617-868-5500
Mailing Address - Fax:
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 63
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:617-868-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18021261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental