Healthcare Provider Details

I. General information

NPI: 1104592724
Provider Name (Legal Business Name): DR. ANNA M BETLEJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 09/15/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5328 COLDWATER RD
FORT WAYNE IN
46825-5445
US

IV. Provider business mailing address

5328 COLDWATER RD
FORT WAYNE IN
46825-5445
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-5016
  • Fax:
Mailing address:
  • Phone: 260-471-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12013698A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: