Provider Demographics
NPI:1710136635
Name:FORD, ANGELIQUE
Entity Type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 E 33RD PL
Mailing Address - Street 2:607
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:533 E 33RD PL
Practice Address - Street 2:607
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4112
Practice Address - Country:US
Practice Address - Phone:773-544-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210022811223E0200X
IL0190267181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice