Provider Demographics
NPI:1669415469
Name:FORSMARK, SCOTT A (DDS)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:FORSMARK
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 1:1346 MACKINAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-1003
Mailing Address - Country:US
Mailing Address - Phone:231-627-5681
Mailing Address - Fax:
Practice Address - Street 1:1346 MACKINAW AVE
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1003
Practice Address - Country:US
Practice Address - Phone:231-627-5681
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010154371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice