Provider Demographics
NPI:1063657187
Name:FORTVILLE FAMILY DENISTRY LLC
Entity Type:Organization
Organization Name:FORTVILLE FAMILY DENISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LACONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-485-5251
Mailing Address - Street 1:14 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-1315
Mailing Address - Country:US
Mailing Address - Phone:317-485-5251
Mailing Address - Fax:
Practice Address - Street 1:14 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-1315
Practice Address - Country:US
Practice Address - Phone:317-485-5251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008802B122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty