Provider Demographics
NPI:1730282344
Name:DEFOREST DENTAL SERVICES
Entity Type:Organization
Organization Name:DEFOREST DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-846-3948
Mailing Address - Street 1:210 N. MAIN ST.
Mailing Address - Street 2:STE 103
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-846-3948
Mailing Address - Fax:608-846-7526
Practice Address - Street 1:210 N. MAIN ST.
Practice Address - Street 2:STE 103
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532
Practice Address - Country:US
Practice Address - Phone:608-846-3948
Practice Address - Fax:608-846-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2412WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty