MEDICARE: DR. LAVELLE FORD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	17564	TX

General Provider Information

NPI Number	:	1184626210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAVELLE FORD DDS

Provider Business Mailing Address
First Line	:	2030 HEIGHTS DR
Second Line	:	STE 3
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-2185
Country	:	US
Telephone Number	:	254-699-9500
Fax Number	:	254-699-2796

Provider Business Practice Location Address
First Line	:	2030 HEIGHTS DR
Second Line	:	STE 3
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-2185
Country	:	US
Telephone Number	:	254-699-9500
Fax Number	:	254-699-2796

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/09/2007

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