Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | D009682 | AZ |
NPI | 1073040358 |
---|---|
Provider Name | Dr. Ross Lucas Forrester |
First Address | Okmulgee, OK 74447-3551 |
Second Address | Eufaula, OK 74432-3249 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2017 |
Last Update Date | 17/05/2017 |