Provider Demographics
NPI:1437602521
Name:OMNI DENTAL PC
Entity Type:Organization
Organization Name:OMNI DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CREAGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-203-4920
Mailing Address - Street 1:10020 DUPONT CIRCLE CT
Mailing Address - Street 2:STE 150
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1620
Mailing Address - Country:US
Mailing Address - Phone:260-203-4920
Mailing Address - Fax:260-203-4923
Practice Address - Street 1:10020 DUPONT CIRCLE CT
Practice Address - Street 2:STE 150
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1620
Practice Address - Country:US
Practice Address - Phone:260-203-4920
Practice Address - Fax:260-203-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011483A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty