Provider Demographics
NPI:1508248360
Name:UNIVERSITY PARK FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:UNIVERSITY PARK FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-272-4441
Mailing Address - Street 1:16597 STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1461
Mailing Address - Country:US
Mailing Address - Phone:574-272-4441
Mailing Address - Fax:574-968-0689
Practice Address - Street 1:16597 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1461
Practice Address - Country:US
Practice Address - Phone:574-272-4441
Practice Address - Fax:574-968-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1200922721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200261730Medicaid