Healthcare Provider Details

I. General information

NPI: 1609938406
Provider Name (Legal Business Name): HENRY C FORD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 ACADEMY ST STE 1
PRESQUE ISLE ME
04769-3178
US

IV. Provider business mailing address

181 ACADEMY ST STE 1
PRESQUE ISLE ME
04769-3178
US

V. Phone/Fax

Practice location:
  • Phone: 207-764-6337
  • Fax: 207-764-1446
Mailing address:
  • Phone: 207-764-6337
  • Fax: 207-764-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3426
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3224
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDEN3426
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: