Provider Demographics
NPI:1568580470
Name:DENTAL CONSULTS OF NORTHEAST INDIANA, PC
Entity Type:Organization
Organization Name:DENTAL CONSULTS OF NORTHEAST INDIANA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:260-489-6544
Mailing Address - Street 1:11115 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9536
Mailing Address - Country:US
Mailing Address - Phone:260-489-6544
Mailing Address - Fax:260-416-0544
Practice Address - Street 1:11115 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9536
Practice Address - Country:US
Practice Address - Phone:260-489-6544
Practice Address - Fax:260-416-0544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120087921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty