Provider Demographics
NPI:1437385465
Name:SAMUEL T JUDD DDS LLC
Entity Type:Organization
Organization Name:SAMUEL T JUDD DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-533-7621
Mailing Address - Street 1:201 PRINGLE DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1419
Mailing Address - Country:US
Mailing Address - Phone:574-533-7621
Mailing Address - Fax:
Practice Address - Street 1:201 PRINGLE DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1419
Practice Address - Country:US
Practice Address - Phone:574-533-7621
Practice Address - Fax:574-533-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120074831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty