Provider Demographics
NPI:1750660221
Name:POPOVICH DENTAL CORPORATION
Entity Type:Organization
Organization Name:POPOVICH DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:POPOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-663-0252
Mailing Address - Street 1:223 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3951
Mailing Address - Country:US
Mailing Address - Phone:219-663-0252
Mailing Address - Fax:219-663-3249
Practice Address - Street 1:223 S COURT ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3951
Practice Address - Country:US
Practice Address - Phone:219-663-0252
Practice Address - Fax:219-663-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006634122300000X
IN12010460A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty