Healthcare Provider Details

I. General information

NPI: 1508969916
Provider Name (Legal Business Name): SAMUEL THOMAS JUDD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PRINGLE DR
GOSHEN IN
46526
US

IV. Provider business mailing address

201 PRINGLE DR
GOSHEN IN
46526
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-7621
  • Fax: 574-533-1072
Mailing address:
  • Phone: 574-533-7621
  • Fax: 574-533-1072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12007483A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: