Healthcare Provider Details

I. General information

NPI: 1184156127
Provider Name (Legal Business Name): FORREST JOHN PRATT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2979 W ELLIOT RD STE 4
CHANDLER AZ
85224-1641
US

IV. Provider business mailing address

2979 W ELLIOT RD STE 4
CHANDLER AZ
85224-1641
US

V. Phone/Fax

Practice location:
  • Phone: 480-775-1304
  • Fax:
Mailing address:
  • Phone: 480-775-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD010864
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: