Provider Demographics
NPI:1801300082
Name:THOMAS P JUDD DDS LLC
Entity type:Organization
Organization Name:THOMAS P JUDD DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-533-7621
Mailing Address - Street 1:201 PRINGLE DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1419
Mailing Address - Country:US
Mailing Address - Phone:574-533-7621
Mailing Address - Fax:574-533-1072
Practice Address - Street 1:201 PRINGLE DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1419
Practice Address - Country:US
Practice Address - Phone:574-533-7621
Practice Address - Fax:574-533-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-26
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011153A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1952565772OtherINDIVIDUAL NPI