Provider Demographics
NPI:1790888170
Name:INDIANA DENTAL CLINIC PC
Entity Type:Organization
Organization Name:INDIANA DENTAL CLINIC PC
Other - Org Name:ATLANTA DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-292-2366
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:IN
Mailing Address - Zip Code:46031
Mailing Address - Country:US
Mailing Address - Phone:765-292-2366
Mailing Address - Fax:765-292-2081
Practice Address - Street 1:29101 ST RD 19
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:IN
Practice Address - Zip Code:46031
Practice Address - Country:US
Practice Address - Phone:765-292-2366
Practice Address - Fax:765-292-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty