Provider Demographics
NPI:1558595777
Name:DENTURES ONLY P.C.
Entity Type:Organization
Organization Name:DENTURES ONLY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-455-0085
Mailing Address - Street 1:1445 W HOOSIER BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-3727
Mailing Address - Country:US
Mailing Address - Phone:765-689-7096
Mailing Address - Fax:
Practice Address - Street 1:1445 W HOOSIER BLVD
Practice Address - Street 2:STE 103
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3727
Practice Address - Country:US
Practice Address - Phone:765-689-7096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100320050Medicaid