Provider Demographics
NPI:1720445737
Name:FORUM DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:FORUM DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:LAMARCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-357-1818
Mailing Address - Street 1:15129 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9036
Mailing Address - Country:US
Mailing Address - Phone:425-357-1818
Mailing Address - Fax:
Practice Address - Street 1:15129 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9036
Practice Address - Country:US
Practice Address - Phone:425-357-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004762261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental