Provider Demographics
NPI:1477869378
Name:LAFAYETTE PEDIATRIC DENTISTRY & ORTHODONTICS
Entity Type:Organization
Organization Name:LAFAYETTE PEDIATRIC DENTISTRY & ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:765-447-6808
Mailing Address - Street 1:2347 CASON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2670
Mailing Address - Country:US
Mailing Address - Phone:765-447-6808
Mailing Address - Fax:
Practice Address - Street 1:2347 CASON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2670
Practice Address - Country:US
Practice Address - Phone:765-447-6808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009779A122300000X
IN12006588A122300000X
IN12011006A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty