Provider Demographics
NPI:1205372356
Name:DENTAL PROFESSIONALS OF INDIANA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF INDIANA, P.C.
Other - Org Name:BRENNAN DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:330 PARK PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3555
Mailing Address - Country:US
Mailing Address - Phone:574-259-9956
Mailing Address - Fax:
Practice Address - Street 1:330 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3555
Practice Address - Country:US
Practice Address - Phone:574-259-9956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF INDIANA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty