Provider Demographics
NPI:1689185886
Name:FORT WAYNE PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:FORT WAYNE PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUDWIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-929-6739
Mailing Address - Street 1:378 ELDERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-4510
Mailing Address - Country:US
Mailing Address - Phone:219-929-6739
Mailing Address - Fax:
Practice Address - Street 1:10211 DUPONT CIRCLE DR W
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1622
Practice Address - Country:US
Practice Address - Phone:260-490-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011802A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty