Healthcare Provider Details

I. General information

NPI: 1750478533
Provider Name (Legal Business Name): KEVIN D WARD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11959 LAKESIDE DRIVE
FISHERS IN
46038-1316
US

IV. Provider business mailing address

11959 LAKESIDE DRIVE
FISHERS IN
46038-1316
US

V. Phone/Fax

Practice location:
  • Phone: 317-577-1911
  • Fax: 317-576-8070
Mailing address:
  • Phone: 317-577-1911
  • Fax: 317-576-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008832
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: