Healthcare Provider Details

I. General information

NPI: 1043672967
Provider Name (Legal Business Name): MICHAEL FORMAN D.M.D. , M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 12/24/2022
Certification Date: 12/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAPLE AVE
GREENWICH CT
06830-5675
US

IV. Provider business mailing address

23 MAPLE AVE
GREENWICH CT
06830-5675
US

V. Phone/Fax

Practice location:
  • Phone: 203-661-5858
  • Fax:
Mailing address:
  • Phone: 203-661-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number062428
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13252
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: