Provider Demographics
NPI:1063254282
Name:ROSS, ANDREW MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:ROSS
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 1:10011 WOODSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7007
Mailing Address - Country:US
Mailing Address - Phone:765-464-9533
Mailing Address - Fax:
Practice Address - Street 1:12962 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9517
Practice Address - Country:US
Practice Address - Phone:260-637-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014464A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist