Provider Demographics
NPI:1710498514
Name:GERALD L IGNACE INDIAN DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:GERALD L IGNACE INDIAN DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DANDRE
Authorized Official - Middle Name:LASHUN
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-316-5052
Mailing Address - Street 1:930 W HISTORIC MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:414-389-9526
Mailing Address - Fax:414-649-2711
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:414-389-9526
Practice Address - Fax:414-649-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty