Provider Demographics
NPI:1457462590
Name:FAMILY DENTISTRY & AESTHETIC INC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY & AESTHETIC INC
Other - Org Name:THOMAS T TEEL THOMAS M GILBERT & CATHERINE N PERIOLAT
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:TEEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-432-0561
Mailing Address - Street 1:4626 WEST JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-432-0561
Mailing Address - Fax:260-436-4626
Practice Address - Street 1:4626 WEST JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-432-0561
Practice Address - Fax:260-436-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN90471223G0001X
IN97571223G0001X
IN120098821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty