1457331332 NPI number — DR. MARVIN PRESTON EADY JR. DDS

Table of content: DR. MARVIN PRESTON EADY JR. DDS (NPI 1457331332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457331332 NPI number — DR. MARVIN PRESTON EADY JR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EADY
Provider First Name:
MARVIN
Provider Middle Name:
PRESTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457331332
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4646 W JEFFERSON BLVD
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-6842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-459-1415
Provider Business Mailing Address Fax Number:
260-459-1419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4646 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-459-1415
Provider Business Practice Location Address Fax Number:
260-459-1419
Provider Enumeration Date:
01/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12009115A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com