Healthcare Provider Details

I. General information

NPI: 1952464182
Provider Name (Legal Business Name): ELIZABETH L. FORKKIO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839-A QUINCE ORCHARD BLVD
GAITHERSBURG MD
20878
US

IV. Provider business mailing address

10408 CAPEHART COURT
GAITHERSBURG MD
20886
US

V. Phone/Fax

Practice location:
  • Phone: 917-561-4858
  • Fax:
Mailing address:
  • Phone: 917-561-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13928
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDEN10000423
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: