Healthcare Provider Details

I. General information

NPI: 1790127173
Provider Name (Legal Business Name): NEWSOM FORESTER DENTAL PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 CALIFORNIA BLVD SUITE G
SAN LUIS OBISPO CA
93401-2541
US

IV. Provider business mailing address

620 CALIFORNIA BLVD SUITE G
SAN LUIS OBISPO CA
93401-2541
US

V. Phone/Fax

Practice location:
  • Phone: 805-592-2020
  • Fax: 805-592-2022
Mailing address:
  • Phone: 805-592-2020
  • Fax: 805-592-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number55823
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number50253
License Number StateCA

VIII. Authorized Official

Name: DR. JAMES ALEXANDER FORESTER
Title or Position: CO-OWNER/PARTNER
Credential: DDS
Phone: 805-592-2020