Healthcare Provider Details

I. General information

NPI: 1255452389
Provider Name (Legal Business Name): MICHAEL JOHN FOURMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5735 MEEKER RD
GREENVILLE OH
45331-1180
US

IV. Provider business mailing address

5735 MEEKER RD
GREENVILLE OH
45331-1180
US

V. Phone/Fax

Practice location:
  • Phone: 937-547-2326
  • Fax: 937-548-3552
Mailing address:
  • Phone: 937-547-2326
  • Fax: 937-548-3552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14663
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: