Healthcare Provider Details

I. General information

NPI: 1659357846
Provider Name (Legal Business Name): DOUGLAS E. FORD DDS, MS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W WACKERLY ST
MIDLAND MI
48640-4716
US

IV. Provider business mailing address

810 W WACKERLY ST
MIDLAND MI
48640-4716
US

V. Phone/Fax

Practice location:
  • Phone: 989-631-9860
  • Fax: 989-631-3996
Mailing address:
  • Phone: 989-631-9860
  • Fax: 989-631-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901015600
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberID # 2901015600
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: