Provider Demographics
NPI:1407479058
Name:DOGWOOD DENTAL LLC
Entity Type:Organization
Organization Name:DOGWOOD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICKOLAUS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-279-9767
Mailing Address - Street 1:1545 J ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3839
Mailing Address - Country:US
Mailing Address - Phone:812-279-9767
Mailing Address - Fax:812-279-5971
Practice Address - Street 1:262 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:IN
Practice Address - Zip Code:47452-1426
Practice Address - Country:US
Practice Address - Phone:812-279-9767
Practice Address - Fax:812-279-5971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental