Provider Demographics
NPI:1255478053
Name:FORD, LISA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:FORD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 RICHMOND ROAD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336
Mailing Address - Country:US
Mailing Address - Phone:606-723-4112
Mailing Address - Fax:606-723-5372
Practice Address - Street 1:161 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336
Practice Address - Country:US
Practice Address - Phone:606-723-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY76471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000536Medicaid