Provider Demographics
NPI:1043234578
Name:FORD, BRAD N (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:N
Last Name:FORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-1625
Mailing Address - Country:US
Mailing Address - Phone:229-273-3828
Mailing Address - Fax:229-273-3829
Practice Address - Street 1:301 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-1625
Practice Address - Country:US
Practice Address - Phone:229-273-3828
Practice Address - Fax:229-273-3829
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA89861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00181607AMedicaid
GA9180322OtherWELLCARE PROVIDER