Provider Demographics
NPI:1922167188
Name:FORT WAYNE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:FORT WAYNE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-432-3459
Mailing Address - Street 1:7202 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2222
Mailing Address - Country:US
Mailing Address - Phone:260-432-3459
Mailing Address - Fax:260-436-4757
Practice Address - Street 1:7202 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2222
Practice Address - Country:US
Practice Address - Phone:260-432-3459
Practice Address - Fax:260-436-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120081271223G0001X
IN12010298A1223G0001X
IN120091991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty