Healthcare Provider Details

I. General information

NPI: 1578799862
Provider Name (Legal Business Name): BRIAN P. FORD D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD 4TH FLOOR, SOUTH PAVILION
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

3400 CIVIC CENTER BLVD 4TH FLOOR, SOUTH PAVILION
PHILADELPHIA PA
19104-5127
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3580
  • Fax:
Mailing address:
  • Phone: 215-662-3580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS037873
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDS037873
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD456122
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: