Provider Demographics
NPI:1417227828
Name:JEFF FORDICE DDS LLC
Entity Type:Organization
Organization Name:JEFF FORDICE DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:FORDICE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-238-4276
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND92971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty