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General NPI Number Information
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NPI Number | 1982411088
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Entity Type | Organization
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Legal Business Name | NORTHEAST INDIANA ORTHODONTICS, LLC
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Dates
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Enumeration Date | 12/12/2024
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 2121 E DUPONT RD STE D
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City | FORT WAYNE
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State | IN
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Zip | 46825-1546
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Country | US
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Telephone | 260-338-2643
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Fax |
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Provider Business Mailing Address
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Address Line | 2121 E DUPONT RD STE D
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City | FORT WAYNE
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State | IN
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Zip | 46825-1546
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Country | US
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Telephone | 260-338-2643
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, ORTHODONTIST
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Name | DR. ALLISON BERGDOLL
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Credential | DDS, MS
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Telephone | 260-338-2643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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