Provider Demographics
NPI:1124182142
Name:FORD DENTAL CARE
Entity Type:Organization
Organization Name:FORD DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-464-9669
Mailing Address - Street 1:125 N RUST AVE
Mailing Address - Street 2:
Mailing Address - City:GENTRY
Mailing Address - State:AR
Mailing Address - Zip Code:72734
Mailing Address - Country:US
Mailing Address - Phone:479-736-8789
Mailing Address - Fax:479-736-5011
Practice Address - Street 1:125 N RUST AVE
Practice Address - Street 2:
Practice Address - City:GENTRY
Practice Address - State:AR
Practice Address - Zip Code:72734
Practice Address - Country:US
Practice Address - Phone:479-736-8789
Practice Address - Fax:479-736-5011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty