Provider Demographics
NPI:1366001679
Name:BONTRAGER FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:BONTRAGER FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KALYSSA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:BONTRAGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-580-5246
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:STROH
Mailing Address - State:IN
Mailing Address - Zip Code:46789-0183
Mailing Address - Country:US
Mailing Address - Phone:260-580-5246
Mailing Address - Fax:
Practice Address - Street 1:612 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2314
Practice Address - Country:US
Practice Address - Phone:260-463-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty