Healthcare Provider Details

I. General information

NPI: 1548388523
Provider Name (Legal Business Name): THOMAS MICHAEL FORD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S 300 E
PROVO UT
84606-3201
US

IV. Provider business mailing address

10 S 300 E
PROVO UT
84606-3201
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-8770
  • Fax: 801-375-0397
Mailing address:
  • Phone: 801-375-8770
  • Fax: 801-375-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number137288-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: