Provider Demographics
NPI:1134253651
Name:FORUM, RICHARD BURTON (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BURTON
Last Name:FORUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SE 18TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2818
Mailing Address - Country:US
Mailing Address - Phone:954-523-5465
Mailing Address - Fax:
Practice Address - Street 1:320 SE 18TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2818
Practice Address - Country:US
Practice Address - Phone:954-523-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist