Provider Demographics
NPI:1518025048
Name:MOORESVILLE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MOORESVILLE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-831-6000
Mailing Address - Street 1:565 S STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2792
Mailing Address - Country:US
Mailing Address - Phone:317-831-6000
Mailing Address - Fax:317-831-4777
Practice Address - Street 1:565 S STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2792
Practice Address - Country:US
Practice Address - Phone:317-831-6000
Practice Address - Fax:317-831-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty