Provider Demographics
NPI:1467612481
Name:THE DENTAL PLACE
Entity Type:Organization
Organization Name:THE DENTAL PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-282-5655
Mailing Address - Street 1:1804 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2209
Mailing Address - Country:US
Mailing Address - Phone:765-282-5655
Mailing Address - Fax:765-587-0103
Practice Address - Street 1:1804 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2209
Practice Address - Country:US
Practice Address - Phone:765-282-5655
Practice Address - Fax:765-587-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007367A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200888590Medicaid