Provider Demographics
NPI:1699833210
Name:ANDREW E FORMAN ORTHODONTICS LLC
Entity Type:Organization
Organization Name:ANDREW E FORMAN ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:E
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:602-843-1000
Mailing Address - Street 1:7119 E SHEA BLVD
Mailing Address - Street 2:SUITE # 109-312
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6107
Mailing Address - Country:US
Mailing Address - Phone:602-843-1000
Mailing Address - Fax:480-443-7165
Practice Address - Street 1:20100 N 51ST AVE
Practice Address - Street 2:SUITE B230
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5125
Practice Address - Country:US
Practice Address - Phone:602-843-1000
Practice Address - Fax:480-443-7165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty