Provider Demographics
NPI:1548709900
Name:DOCTOR EADY FAMILY DENTISTRY, P.C.
Entity type:Organization
Organization Name:DOCTOR EADY FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:EADY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-459-1415
Mailing Address - Street 1:4646 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6842
Mailing Address - Country:US
Mailing Address - Phone:260-459-1415
Mailing Address - Fax:260-459-1419
Practice Address - Street 1:4646 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6842
Practice Address - Country:US
Practice Address - Phone:260-459-1415
Practice Address - Fax:260-459-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120091151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty