Provider Demographics
NPI:1639541816
Name:FORST, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FORST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10514 SW NAEVE ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3516
Mailing Address - Country:US
Mailing Address - Phone:503-598-9206
Mailing Address - Fax:
Practice Address - Street 1:17675 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-4443
Practice Address - Country:US
Practice Address - Phone:503-259-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant