Provider Demographics
NPI:1609190719
Name:DENTAL HEALTH ASSOC OF IN
Entity Type:Organization
Organization Name:DENTAL HEALTH ASSOC OF IN
Other - Org Name:ELLETTSVILLE GENTLE DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-359-3888
Mailing Address - Street 1:3617 W STATE ROAD 46
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-9152
Mailing Address - Country:US
Mailing Address - Phone:812-876-0007
Mailing Address - Fax:
Practice Address - Street 1:3617 W STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9152
Practice Address - Country:US
Practice Address - Phone:812-876-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty