Provider Demographics
NPI:1003172008
Name:HEALTHY SMILES NWI
Entity Type:Organization
Organization Name:HEALTHY SMILES NWI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-260-3544
Mailing Address - Street 1:4629 MELTON RD.
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403
Mailing Address - Country:US
Mailing Address - Phone:219-938-2637
Mailing Address - Fax:219-938-6338
Practice Address - Street 1:4629 MELTON RD.
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403
Practice Address - Country:US
Practice Address - Phone:219-938-2637
Practice Address - Fax:219-938-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011235A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200992160Medicaid