Provider Demographics
NPI:1184006959
Name:RONALD JAY MUNDEN, D.D.S.
Entity Type:Organization
Organization Name:RONALD JAY MUNDEN, D.D.S.
Other - Org Name:MUNDEN FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:MUNDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-384-4191
Mailing Address - Street 1:124 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:47424-1045
Mailing Address - Country:US
Mailing Address - Phone:812-384-4191
Mailing Address - Fax:812-384-4191
Practice Address - Street 1:124 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IN
Practice Address - Zip Code:47424-1045
Practice Address - Country:US
Practice Address - Phone:812-384-4191
Practice Address - Fax:812-384-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008928A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124920Medicaid