Provider Demographics
NPI:1477176253
Name:MY RIVERTOWN DENTIST LLC
Entity Type:Organization
Organization Name:MY RIVERTOWN DENTIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-273-2388
Mailing Address - Street 1:2513 MICHIGAN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2422
Mailing Address - Country:US
Mailing Address - Phone:812-273-2388
Mailing Address - Fax:
Practice Address - Street 1:2513 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2422
Practice Address - Country:US
Practice Address - Phone:812-273-2388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty