Provider Demographics
NPI:1760762108
Name:JEFFERSON DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:JEFFERSON DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:MONT
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-233-7266
Mailing Address - Street 1:2628 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2724
Mailing Address - Country:US
Mailing Address - Phone:574-233-7266
Mailing Address - Fax:574-233-7560
Practice Address - Street 1:2628 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2724
Practice Address - Country:US
Practice Address - Phone:574-233-7266
Practice Address - Fax:574-233-7560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009908 A261QD0000X
IN12007912 A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100222700AMedicaid
IN200496100AMedicaid