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NPI Code Detail

MEDICARE: PEDIATRIC DENTISTRY INC

MEDICARE: PEDIATRIC DENTISTRY INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223P0221XPediatric Dentistry54000382AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1104667OTHERININD DEPT OF HEALTH CHILDR

General Provider Information

NPI Number : 1104859701
Entity Type Code : Organization
Provider Name (Legal Business Name) : PEDIATRIC DENTISTRY INC
Provider Business Mailing Address
First Line : 7750 WEST JEFFERSON BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-4136
Country : US
Telephone Number : 260-459-0903
Fax Number : 260-459-0673
Provider Business Practice Location Address
First Line : 7750 WEST JEFFERSON BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-4136
Country : US
Telephone Number : 260-459-0903
Fax Number : 260-459-0673
Authorized Official
Title or Position : PRESIDENT OWNER
Name : DR. WAYNE LEE DAWES
Credential : DDS
Telephone Number : 260-459-0903
Provider Enumeration Date : 07/08/2006
Last Update Date : 08/22/2020

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Directions to “PEDIATRIC DENTISTRY INC ” Practice Location

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