Provider Demographics
NPI:1053199539
Name:PRIME DENTAL CARE LLC
Entity type:Organization
Organization Name:PRIME DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY KUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GODI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-788-5803
Mailing Address - Street 1:3210 TROUTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8791
Mailing Address - Country:US
Mailing Address - Phone:419-788-5803
Mailing Address - Fax:
Practice Address - Street 1:435 W COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1010
Practice Address - Country:US
Practice Address - Phone:260-263-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty