Provider Demographics
NPI:1720425010
Name:HERTIG, ADAM RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:RICHARD
Last Name:HERTIG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5666
Mailing Address - Country:US
Mailing Address - Phone:260-486-3100
Mailing Address - Fax:
Practice Address - Street 1:4109 LAHMEYER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-5666
Practice Address - Country:US
Practice Address - Phone:260-486-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011943A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist