Provider Demographics
NPI:1639173404
Name:FORMAN, SPENCER Z (DMD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:Z
Last Name:FORMAN
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 1:3 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:JAMESBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1312
Mailing Address - Country:US
Mailing Address - Phone:732-521-0294
Mailing Address - Fax:732-521-6061
Practice Address - Street 1:3 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JAMESBURG
Practice Address - State:NJ
Practice Address - Zip Code:08831-1312
Practice Address - Country:US
Practice Address - Phone:732-521-0294
Practice Address - Fax:732-521-6061
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ107831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice