Provider Demographics
NPI:1689122491
Name:PLYMOUTH 20/20 DENTAL, LLC
Entity Type:Organization
Organization Name:PLYMOUTH 20/20 DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:I
Authorized Official - Last Name:PROKES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-601-6010
Mailing Address - Street 1:1409 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1119
Mailing Address - Country:US
Mailing Address - Phone:574-936-8787
Mailing Address - Fax:
Practice Address - Street 1:1409 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1119
Practice Address - Country:US
Practice Address - Phone:574-936-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:20/20 DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty