Provider Demographics
NPI:1114016201
Name:MARC J MEADOWS DDS PC
Entity Type:Organization
Organization Name:MARC J MEADOWS DDS PC
Other - Org Name:WOODSCREST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MEADOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-332-0866
Mailing Address - Street 1:515 S WOODSCREST DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5524
Mailing Address - Country:US
Mailing Address - Phone:812-332-0866
Mailing Address - Fax:
Practice Address - Street 1:515 S WOODSCREST DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5524
Practice Address - Country:US
Practice Address - Phone:812-332-0866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120104151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty