Provider Demographics
NPI:1629443809
Name:HOOSIER DENTIST LLC
Entity Type:Organization
Organization Name:HOOSIER DENTIST LLC
Other - Org Name:WELLNESS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DHAENENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-309-5860
Mailing Address - Street 1:2900 W RAY RD
Mailing Address - Street 2:STE 3
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:574-309-5860
Mailing Address - Fax:
Practice Address - Street 1:2900 W RAY RD
Practice Address - Street 2:STE 3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:574-309-5860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ161222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental