1033370069 NPI number — DR. FORREST FAULKNER DMD

Table of content: DR. FORREST FAULKNER DMD (NPI 1033370069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033370069 NPI number — DR. FORREST FAULKNER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAULKNER
Provider First Name:
FORREST
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033370069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
548 WINDROSE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32507-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-585-1257
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4041 HIGHWAY 90
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32571-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-994-8185
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN 18344 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)