Provider Demographics
NPI:1366636870
Name:EAST WARSAW DENTAL GROUP LLC
Entity Type:Organization
Organization Name:EAST WARSAW DENTAL GROUP LLC
Other - Org Name:EAST CENTER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-269-1787
Mailing Address - Street 1:2104 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3704
Mailing Address - Country:US
Mailing Address - Phone:574-269-1787
Mailing Address - Fax:574-267-1610
Practice Address - Street 1:2104 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3704
Practice Address - Country:US
Practice Address - Phone:574-269-1787
Practice Address - Fax:574-267-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000313A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty