Healthcare Provider Details

I. General information

NPI: 1376635375
Provider Name (Legal Business Name): FORREST GARNETT BALE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S GLENWOOD AVE
RUSSELLVILLE AR
72801-5906
US

IV. Provider business mailing address

319 S GLENWOOD AVE
RUSSELLVILLE AR
72801-5906
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-1334
  • Fax:
Mailing address:
  • Phone: 479-968-1334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE00010370
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3799
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: