Healthcare Provider Details

I. General information

NPI: 1205730215
Provider Name (Legal Business Name): ORCHARD DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4716 ILLINOIS RD STE 101
FORT WAYNE IN
46804-5123
US

IV. Provider business mailing address

PO BOX 70887
CLEVELAND OH
44190-0887
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-7970
  • 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 StateNULL

VIII. Authorized Official

Name: MARIANNE TILTON
Title or Position: PROVIDER ENROLLMENT SUPERVISOR
Credential:
Phone: 315-454-6000