Healthcare Provider Details

I. General information

NPI: 1780235374
Provider Name (Legal Business Name): KATHRYN WELCH DDS, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E TILLMAN RD
FORT WAYNE IN
46816-1079
US

IV. Provider business mailing address

4717 OLD MILL RD
FORT WAYNE IN
46807-2925
US

V. Phone/Fax

Practice location:
  • Phone: 260-447-2568
  • Fax:
Mailing address:
  • Phone: 260-417-5623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.025898
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12012731A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: