Provider Demographics
NPI:1093017907
Name:LADD DENTAL GROUP OF PERU, P.C.
Entity Type:Organization
Organization Name:LADD DENTAL GROUP OF PERU, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-455-0085
Mailing Address - Street 1:2333 W LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8012
Mailing Address - Country:US
Mailing Address - Phone:765-455-0085
Mailing Address - Fax:765-455-6839
Practice Address - Street 1:980 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1070
Practice Address - Country:US
Practice Address - Phone:765-473-0141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty