Provider Demographics
NPI:1497906556
Name:ROSENTHALL ORTHODONTICS
Entity Type:Organization
Organization Name:ROSENTHALL ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSENTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:765-289-2377
Mailing Address - Street 1:610 SOUTH YILLOTSON AVENUE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4450
Mailing Address - Country:US
Mailing Address - Phone:765-289-2377
Mailing Address - Fax:765-289-3409
Practice Address - Street 1:610 SOUTH YILLOTSON AVENUE
Practice Address - Street 2:SUITE 210
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4450
Practice Address - Country:US
Practice Address - Phone:765-289-2377
Practice Address - Fax:765-289-3409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120100651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty