Healthcare Provider Details

I. General information

NPI: 1043266653
Provider Name (Legal Business Name): DALE DENNIS DEARDORFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 4TH ST SUITE 180
MISHAWAKA IN
46544-1948
US

IV. Provider business mailing address

PO BOX 6309
SOUTH BEND IN
46660-6309
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-3456
  • Fax: 574-247-3455
Mailing address:
  • Phone: 574-472-6700
  • Fax: 574-472-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01025330
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: