Healthcare Provider Details

I. General information

NPI: 1639260276
Provider Name (Legal Business Name): MICHAEL BRIAN FORMAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/18/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 DIAMOND HILL RD
WOONSOCKET RI
02895-1554
US

IV. Provider business mailing address

2000 DIAMOND HILL RD
WOONSOCKET RI
02895-1554
US

V. Phone/Fax

Practice location:
  • Phone: 401-766-8600
  • Fax: 401-766-8601
Mailing address:
  • Phone: 401-766-8600
  • Fax: 401-766-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN2031
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: