Healthcare Provider Details

I. General information

NPI: 1982411088
Provider Name (Legal Business Name): NORTHEAST INDIANA ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E DUPONT RD STE D
FORT WAYNE IN
46825-1546
US

IV. Provider business mailing address

2121 E DUPONT RD STE D
FORT WAYNE IN
46825-1546
US

V. Phone/Fax

Practice location:
  • Phone: 260-338-2643
  • Fax:
Mailing address:
  • Phone: 260-338-2643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ALLISON BERGDOLL
Title or Position: PRESIDENT, ORTHODONTIST
Credential: DDS, MS
Phone: 260-338-2643