Provider Demographics
NPI:1891883633
Name:BRADFORD H KORN DDS, INC.
Entity Type:Organization
Organization Name:BRADFORD H KORN DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:KORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-432-3588
Mailing Address - Street 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:260-432-3588
Mailing Address - Fax:260-459-0729
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-432-3588
Practice Address - Fax:260-459-0729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007256261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental