Provider Demographics
NPI:1952536518
Name:WEIDA, JOHN PURDUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PURDUE
Last Name:WEIDA
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 1:2250 N PENNSYLVANIA ST
Mailing Address - Street 2:#7
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-4383
Mailing Address - Country:US
Mailing Address - Phone:765-479-8555
Mailing Address - Fax:
Practice Address - Street 1:105 S RACEWAY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46231-1414
Practice Address - Country:US
Practice Address - Phone:765-479-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011295A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist