Healthcare Provider Details

I. General information

NPI: 1093017907
Provider Name (Legal Business Name): LADD DENTAL GROUP OF PERU, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 N BROADWAY
PERU IN
46970-1070
US

IV. Provider business mailing address

2333 W LINCOLN RD
KOKOMO IN
46902-8012
US

V. Phone/Fax

Practice location:
  • Phone: 765-473-0141
  • Fax:
Mailing address:
  • Phone: 765-455-0085
  • Fax: 765-455-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7486
License Number StateIN

VIII. Authorized Official

Name: JOHN RALPH LADD
Title or Position: OWNER/CEO
Credential: D.D.S.
Phone: 765-455-0085