Provider Demographics
NPI:1699033944
Name:MINI DENTAL IMPLANT CENTERS OF AMERICA LLC
Entity Type:Organization
Organization Name:MINI DENTAL IMPLANT CENTERS OF AMERICA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-759-8351
Mailing Address - Street 1:2001 S TIGER DRIVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396
Mailing Address - Country:US
Mailing Address - Phone:765-759-8351
Mailing Address - Fax:765-759-8749
Practice Address - Street 1:2001 S TIGER DRIVE
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396
Practice Address - Country:US
Practice Address - Phone:765-759-8351
Practice Address - Fax:765-759-8749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YORKTOWN FAMILY DENTISTRY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty