Provider Demographics
NPI:1184626210
Name:FORD, LAVELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:LAVELLE
Middle Name:
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 1:2030 HEIGHTS DR
Mailing Address - Street 2:STE 3
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-2185
Mailing Address - Country:US
Mailing Address - Phone:254-699-9500
Mailing Address - Fax:254-699-2796
Practice Address - Street 1:2030 HEIGHTS DR
Practice Address - Street 2:STE 3
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-2185
Practice Address - Country:US
Practice Address - Phone:254-699-9500
Practice Address - Fax:254-699-2796
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU64246Medicare UPIN
00940TMedicare ID - Type Unspecified