Organization
WAYNE YOUTH DENTISTRY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENELL STUMP (MANAGER, LICENSING & CREDENTIALING)
(615) 750-0343
Entity
Organization
Contact information
Practice address
7524 S ANTHONY BLVD, FORT WAYNE, IN 46816-2517
(260) 441-8500
(260) 441-0887
Mailing address
16 ARCADE UNIT 198747, NASHVILLE, TN 37219-1994
(615) 750-0343
(615) 986-1705
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200542880A
—
IN
05
—
2619223
—
OH
Enumeration date
05/04/2006
Last updated
07/09/2014
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