Provider Demographics
NPI:1851588628
Name:FORST, DANE GEORGE
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:GEORGE
Last Name:FORST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 N ROCKY POINT DR
Mailing Address - Street 2:SUITE- 1000
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1421
Mailing Address - Country:US
Mailing Address - Phone:813-288-1999
Mailing Address - Fax:
Practice Address - Street 1:3466 CLARK ROAD
Practice Address - Street 2:SUITE- 410
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-927-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN49221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice