Healthcare Provider Details

I. General information

NPI: 1649336579
Provider Name (Legal Business Name): THOMAS G. WUNDER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W SYCAMORE ST
NORTH JUDSON IN
46366-1246
US

IV. Provider business mailing address

106 W SYCAMORE ST
NORTH JUDSON IN
46366-1246
US

V. Phone/Fax

Practice location:
  • Phone: 574-896-2512
  • Fax: 574-896-2051
Mailing address:
  • Phone: 574-896-2512
  • Fax: 574-896-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12006753A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: