Healthcare Provider Details

I. General information

NPI: 1508970088
Provider Name (Legal Business Name): ERIC LEE DELLINGER D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E DUPONT RD
FORT WAYNE IN
46825-1556
US

IV. Provider business mailing address

1120 E DUPONT RD
FORT WAYNE IN
46825-1556
US

V. Phone/Fax

Practice location:
  • Phone: 260-497-0497
  • Fax: 260-489-4853
Mailing address:
  • Phone: 260-497-0497
  • Fax: 260-489-4853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009227A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: