Healthcare Provider Details

I. General information

NPI: 1205418258
Provider Name (Legal Business Name): DHDA WFD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3146 N NATIONAL RD
COLUMBUS IN
47201-3169
US

IV. Provider business mailing address

120 WEBSTER ST STE 332
LOUISVILLE KY
40206-1895
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-5568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PAUL LAVELLE
Title or Position: SOLE MEMBER OF DHDA PROVIDERCO PLLC
Credential: DMD
Phone: 502-228-0234