Provider Demographics
NPI:1841640521
Name:RAMTHUN, ANDREA (DDS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RAMTHUN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 S ESTHER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-1440
Mailing Address - Country:US
Mailing Address - Phone:574-307-7673
Mailing Address - Fax:574-234-4705
Practice Address - Street 1:1002 S ESTHER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1440
Practice Address - Country:US
Practice Address - Phone:574-307-7673
Practice Address - Fax:574-234-4705
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021848122300000X
IN12012989A1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016368Medicaid