Provider Demographics
NPI:1720174592
Name:FORD, CHRISTINE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BROOKWOOD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5259
Mailing Address - Country:US
Mailing Address - Phone:707-568-7633
Mailing Address - Fax:707-568-7321
Practice Address - Street 1:101 BROOKWOOD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5259
Practice Address - Country:US
Practice Address - Phone:707-568-7633
Practice Address - Fax:707-568-7321
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301021223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics