Provider Demographics
NPI:1528542370
Name:BRAZIL DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:BRAZIL DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-448-3639
Mailing Address - Street 1:21 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-2204
Mailing Address - Country:US
Mailing Address - Phone:812-448-3639
Mailing Address - Fax:
Practice Address - Street 1:21 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2204
Practice Address - Country:US
Practice Address - Phone:812-448-3639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201229120BMedicaid
IN300004053Medicaid
IN201234800AMedicaid