Provider Demographics
NPI:1073656740
Name:MAPLE FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:MAPLE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:DIANN
Authorized Official - Last Name:MAPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-753-4717
Mailing Address - Street 1:718 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-3158
Mailing Address - Country:US
Mailing Address - Phone:574-753-4717
Mailing Address - Fax:574-732-1076
Practice Address - Street 1:718 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-3158
Practice Address - Country:US
Practice Address - Phone:574-753-4717
Practice Address - Fax:574-732-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010584A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty