Provider Demographics
NPI:1780235374
Name:WELCH, KATHRYN (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2925
Mailing Address - Country:US
Mailing Address - Phone:260-417-5623
Mailing Address - Fax:
Practice Address - Street 1:223 E TILLMAN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-1079
Practice Address - Country:US
Practice Address - Phone:260-447-2568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0258981223X0400X
IN12012731A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics