Provider Demographics
NPI:1093122418
Name:MIRACLE LANE FAMILY DENTISTRY P.C.
Entity Type:Organization
Organization Name:MIRACLE LANE FAMILY DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MERRITT-BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-610-4688
Mailing Address - Street 1:2332 MIRACLE LN
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3012
Mailing Address - Country:US
Mailing Address - Phone:574-259-5437
Mailing Address - Fax:574-259-5438
Practice Address - Street 1:2332 MIRACLE LN
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3012
Practice Address - Country:US
Practice Address - Phone:574-259-5437
Practice Address - Fax:574-259-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54001789A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental