Provider Demographics
NPI:1881062941
Name:FORD DENTAL GROUP
Entity type:Organization
Organization Name:FORD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AZIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUKLED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:519-819-7875
Mailing Address - Street 1:5601 SCHAEFER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4713
Mailing Address - Country:US
Mailing Address - Phone:313-582-4800
Mailing Address - Fax:
Practice Address - Street 1:5601 SCHAEFER RD STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4713
Practice Address - Country:US
Practice Address - Phone:313-582-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021724305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization