Provider Demographics
NPI:1760559082
Name:DECATUR DENTAL SERVICES
Entity Type:Organization
Organization Name:DECATUR DENTAL SERVICES
Other - Org Name:GENEVA DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-368-7500
Mailing Address - Street 1:6204 W 300 S-1 # SOUTH-1
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9516
Mailing Address - Country:US
Mailing Address - Phone:260-565-4506
Mailing Address - Fax:
Practice Address - Street 1:447 E LINE ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IN
Practice Address - Zip Code:46740-8936
Practice Address - Country:US
Practice Address - Phone:260-368-7500
Practice Address - Fax:260-368-7167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120104121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty