Provider Demographics
NPI:1568557874
Name:THE CENTER FOR ADVANCED DENTISTRY, LLC
Entity Type:Organization
Organization Name:THE CENTER FOR ADVANCED DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:RECEVEUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-948-2281
Mailing Address - Street 1:819 MOUNT TABOR RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-6414
Mailing Address - Country:US
Mailing Address - Phone:812-948-2281
Mailing Address - Fax:812-945-8374
Practice Address - Street 1:819 MOUNT TABOR RD
Practice Address - Street 2:SUITE 10
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6414
Practice Address - Country:US
Practice Address - Phone:812-948-2281
Practice Address - Fax:812-945-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008027A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherELECTRONIC CLAIMS PROCESS