Provider Demographics
NPI:1083679732
Name:FORDICE, JEFFREY HOWARD (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HOWARD
Last Name:FORDICE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4418
Mailing Address - Country:US
Mailing Address - Phone:507-238-4276
Mailing Address - Fax:507-238-5496
Practice Address - Street 1:1120 BIRCH ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4418
Practice Address - Country:US
Practice Address - Phone:507-238-4276
Practice Address - Fax:507-238-5496
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND92971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice