Provider Demographics
NPI:1417326083
Name:MIDTOWN DENTAL P C
Entity Type:Organization
Organization Name:MIDTOWN DENTAL P C
Other - Org Name:SHAMBAUGH DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-8596
Mailing Address - Street 1:4616 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6826
Mailing Address - Country:US
Mailing Address - Phone:260-432-8596
Mailing Address - Fax:
Practice Address - Street 1:4616 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6826
Practice Address - Country:US
Practice Address - Phone:260-432-8596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty