Provider Demographics
NPI:1457331332
Name:EADY, MARVIN PRESTON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:PRESTON
Last Name:EADY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6842
Mailing Address - Country:US
Mailing Address - Phone:260-459-1415
Mailing Address - Fax:260-459-1419
Practice Address - Street 1:4646 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6842
Practice Address - Country:US
Practice Address - Phone:260-459-1415
Practice Address - Fax:260-459-1419
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009115A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice