Provider Demographics
NPI:1811186323
Name:SELECT DENTISTRY, PC
Entity Type:Organization
Organization Name:SELECT DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-514-8746
Mailing Address - Street 1:1422 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613-3250
Mailing Address - Country:US
Mailing Address - Phone:574-232-8888
Mailing Address - Fax:
Practice Address - Street 1:1422 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613-3250
Practice Address - Country:US
Practice Address - Phone:574-232-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-21
Last Update Date:2007-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010354A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty