Provider Demographics
NPI:1922869015
Name:MIDWEST DENTAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MIDWEST DENTAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE / HR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYER
Authorized Official - Suffix:
Authorized Official - Credentials:AS
Authorized Official - Phone:765-447-9319
Mailing Address - Street 1:415 N 26TH ST STE 303
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2893
Mailing Address - Country:US
Mailing Address - Phone:765-447-9319
Mailing Address - Fax:765-447-7227
Practice Address - Street 1:1650 W OAK ST STE 206
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-3836
Practice Address - Country:US
Practice Address - Phone:317-349-0419
Practice Address - Fax:317-342-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental