Healthcare Provider Details

I. General information

NPI: 1801300082
Provider Name (Legal Business Name): THOMAS P JUDD DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PRINGLE DR
GOSHEN IN
46526-1419
US

IV. Provider business mailing address

201 PRINGLE DR
GOSHEN IN
46526-1419
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number12011153A
License Number StateIN

VIII. Authorized Official

Name: DR. THOMAS PHILLIP JUDD
Title or Position: DENTIST
Credential: DDS
Phone: 574-533-7621