Provider Demographics
NPI:1417150137
Name:MICHIGAN CITY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MICHIGAN CITY FAMILY DENTISTRY
Other - Org Name:PORTAGE DENTAL REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRESHINDA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:AYANGADE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:219-764-4004
Mailing Address - Street 1:6044 LUTE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5008
Mailing Address - Country:US
Mailing Address - Phone:219-764-4004
Mailing Address - Fax:219-764-4031
Practice Address - Street 1:6044 LUTE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5008
Practice Address - Country:US
Practice Address - Phone:219-764-4004
Practice Address - Fax:219-764-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty