Provider Demographics
NPI:1629415419
Name:DEAN FAMILY DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:DEAN FAMILY DENTAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, LLC / OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-425-4251
Mailing Address - Street 1:710 W MILL RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-3928
Mailing Address - Country:US
Mailing Address - Phone:812-425-4251
Mailing Address - Fax:812-425-3086
Practice Address - Street 1:710 W MILL RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-3928
Practice Address - Country:US
Practice Address - Phone:812-425-4251
Practice Address - Fax:812-425-3086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006932A1223G0001X
IN12011866A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100241450AMedicaid