Provider Demographics
NPI:1790712180
Name:FOREST VIEW DENTAL, S.C.
Entity Type:Organization
Organization Name:FOREST VIEW DENTAL, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LASELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-733-1111
Mailing Address - Street 1:1111 W VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1485
Mailing Address - Country:US
Mailing Address - Phone:920-733-1111
Mailing Address - Fax:920-380-4056
Practice Address - Street 1:1111 W VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1485
Practice Address - Country:US
Practice Address - Phone:920-733-1111
Practice Address - Fax:920-380-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3124-0151223G0001X
WI5291-0151223G0001X
WI4766-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty