Provider Demographics
NPI:1710757471
Name:LAGRANGE FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:LAGRANGE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONTRAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-463-2111
Mailing Address - Street 1:612 S DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-2314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2314
Practice Address - Country:US
Practice Address - Phone:260-463-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BONTRAGER FAMILY DENTISTRY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty