Provider Demographics
NPI:1942338231
Name:BITTERSWEET RD. FAMILY DENTIST
Entity Type:Organization
Organization Name:BITTERSWEET RD. FAMILY DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-277-7995
Mailing Address - Street 1:51410 BITTERSWEET RD
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9119
Mailing Address - Country:US
Mailing Address - Phone:574-277-7995
Mailing Address - Fax:574-277-0184
Practice Address - Street 1:51410 BITTERSWEET RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9119
Practice Address - Country:US
Practice Address - Phone:574-277-7995
Practice Address - Fax:574-277-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty