Provider Demographics
NPI:1114362803
Name:JACKSON CREEK DENTAL
Entity Type:Organization
Organization Name:JACKSON CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TSCHETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-336-5525
Mailing Address - Street 1:1124 S COLLEGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6178
Mailing Address - Country:US
Mailing Address - Phone:812-336-5525
Mailing Address - Fax:812-322-5520
Practice Address - Street 1:1124 S COLLEGE MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6178
Practice Address - Country:US
Practice Address - Phone:812-336-5525
Practice Address - Fax:812-322-5520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010765A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty