Provider Demographics
NPI:1710281860
Name:DECATUR DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:DECATUR DENTAL SERVICES, INC.
Other - Org Name:BERNE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-724-8746
Mailing Address - Street 1:525 W PARR RD
Mailing Address - Street 2:
Mailing Address - City:BERNE
Mailing Address - State:IN
Mailing Address - Zip Code:46711-1131
Mailing Address - Country:US
Mailing Address - Phone:260-589-2110
Mailing Address - Fax:260-589-8512
Practice Address - Street 1:525 W PARR RD
Practice Address - Street 2:
Practice Address - City:BERNE
Practice Address - State:IN
Practice Address - Zip Code:46711-1131
Practice Address - Country:US
Practice Address - Phone:260-589-2110
Practice Address - Fax:260-589-8512
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DECATUR DENTAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007836122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty