Provider Demographics
NPI:1427224963
Name:FORD, RANDALL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:FORD
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 1:1740 BIG SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-8206
Mailing Address - Country:US
Mailing Address - Phone:865-681-7645
Mailing Address - Fax:865-681-3488
Practice Address - Street 1:1740 BIG SPRINGS RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-8206
Practice Address - Country:US
Practice Address - Phone:865-681-7645
Practice Address - Fax:865-681-3488
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS5205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDS5205Other1649345406