Provider Demographics
NPI:1326126871
Name:CEDAR LAKE DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:CEDAR LAKE DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:KAZWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-374-5591
Mailing Address - Street 1:13955 MORSE ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9639
Mailing Address - Country:US
Mailing Address - Phone:219-374-5591
Mailing Address - Fax:219-662-2573
Practice Address - Street 1:13955 MORSE ST
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9639
Practice Address - Country:US
Practice Address - Phone:219-374-5591
Practice Address - Fax:219-662-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000250A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty