Provider Demographics
NPI:1487646022
Name:FORD, JERRY DEREK (DDS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DEREK
Last Name:FORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1290
Mailing Address - Street 2:
Mailing Address - City:GENTRY
Mailing Address - State:AR
Mailing Address - Zip Code:72734-1290
Mailing Address - Country:US
Mailing Address - Phone:479-736-8789
Mailing Address - Fax:479-736-5011
Practice Address - Street 1:125 NORTH RUST AVE
Practice Address - Street 2:
Practice Address - City:GENTRY
Practice Address - State:AR
Practice Address - Zip Code:72734
Practice Address - Country:US
Practice Address - Phone:479-736-8789
Practice Address - Fax:479-736-5011
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
AR30951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice