Provider Demographics
NPI:1518412139
Name:FAIRMOUNT FAMILY DENTIST
Entity Type:Organization
Organization Name:FAIRMOUNT FAMILY DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-948-4107
Mailing Address - Street 1:215 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:IN
Mailing Address - Zip Code:46928-1747
Mailing Address - Country:US
Mailing Address - Phone:765-948-4107
Mailing Address - Fax:
Practice Address - Street 1:215 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT
Practice Address - State:IN
Practice Address - Zip Code:46928-1747
Practice Address - Country:US
Practice Address - Phone:765-948-4107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011164A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental