Provider Demographics
NPI:1790366177
Name:FORMAN, ARYEH LEIB (DMD)
Entity Type:Individual
Prefix:DR
First Name:ARYEH
Middle Name:LEIB
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 1:1505 NW 167TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5133
Mailing Address - Country:US
Mailing Address - Phone:847-420-1293
Mailing Address - Fax:
Practice Address - Street 1:1505 NW 167TH ST STE 100
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-5133
Practice Address - Country:US
Practice Address - Phone:305-625-5400
Practice Address - Fax:305-625-8110
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-18
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02862100122300000X
FLDN259491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist