Provider Demographics
NPI:1265546550
Name:FORMAN, STEVEN SAMUEL (DDS)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:SAMUEL
Last Name:FORMAN
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 1:65 MOUNTAIN BLVD EXT
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-2632
Mailing Address - Country:US
Mailing Address - Phone:732-356-1777
Mailing Address - Fax:732-302-3082
Practice Address - Street 1:65 MOUNTAIN BLVD EXT
Practice Address - Street 2:SUITE 204
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-2632
Practice Address - Country:US
Practice Address - Phone:732-356-1777
Practice Address - Fax:732-302-3082
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 011442001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice