Provider Demographics
NPI:1437669967
Name:SALEM FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:SALEM FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:812-883-5804
Mailing Address - Street 1:2126 N STATE ROAD 135
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-6005
Mailing Address - Country:US
Mailing Address - Phone:821-620-1633
Mailing Address - Fax:
Practice Address - Street 1:100 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-1426
Practice Address - Country:US
Practice Address - Phone:812-883-5804
Practice Address - Fax:812-883-0603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010386261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental