Provider Demographics
NPI:1366854143
Name:KENTLAND FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KENTLAND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BODINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-474-5059
Mailing Address - Street 1:310 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:KENTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47951-1135
Mailing Address - Country:US
Mailing Address - Phone:219-474-5059
Mailing Address - Fax:
Practice Address - Street 1:310 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KENTLAND
Practice Address - State:IN
Practice Address - Zip Code:47951-1135
Practice Address - Country:US
Practice Address - Phone:219-474-5059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1639581507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty