=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104859701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTISTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7750 WEST JEFFERSON BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-4136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-459-0903
-----------------------------------------------------
Fax | 260-459-0673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7750 WEST JEFFERSON BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-4136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-459-0903
-----------------------------------------------------
Fax | 260-459-0673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | DR. WAYNE LEE DAWES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 260-459-0903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 54000382A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------