MEDICARE: FAMILY DENTISTRY & AESTHETIC INC

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	1223G0001X	General Practice Dentistry	9047	IN
2	1223G0001X	General Practice Dentistry	9757	IN
3	1223G0001X	General Practice Dentistry	12009882	IN

General Provider Information

NPI Number	:	1457462590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DENTISTRY & AESTHETIC INC

Provider Business Mailing Address
First Line	:	4626 WEST JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	260-432-0561
Fax Number	:	260-436-4626

Provider Business Practice Location Address
First Line	:	4626 WEST JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	260-432-0561
Fax Number	:	260-436-4626

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	DR. THOMAS T TEEL
Credential	:	DDS
Telephone Number	:	260-432-0561

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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