Provider Demographics
NPI:1871517771
Name:FORSYTH, WILLIAM FRED (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:FRED
Last Name:FORSYTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:FRED
Other - Last Name:FORSYTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1615 SANTA FE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9725
Mailing Address - Country:US
Mailing Address - Phone:309-444-4365
Mailing Address - Fax:
Practice Address - Street 1:1215 N NORTH ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1569
Practice Address - Country:US
Practice Address - Phone:309-674-8913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist