Provider Demographics
NPI:1801004874
Name:FORD & DRAPER DENTAL LLC
Entity Type:Organization
Organization Name:FORD & DRAPER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-475-6500
Mailing Address - Street 1:1508 E SKYLINE DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4846
Mailing Address - Country:US
Mailing Address - Phone:801-475-6500
Mailing Address - Fax:801-479-5904
Practice Address - Street 1:1508 E SKYLINE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4846
Practice Address - Country:US
Practice Address - Phone:801-475-6500
Practice Address - Fax:801-479-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529356756000Medicaid
UT529356730001Medicaid