Provider Demographics
NPI:1134401144
Name:MONROVIA DENTAL CLINIC, LLC
Entity type:Organization
Organization Name:MONROVIA DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-996-3391
Mailing Address - Street 1:253 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:IN
Mailing Address - Zip Code:46157-9567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:IN
Practice Address - Zip Code:46157-9567
Practice Address - Country:US
Practice Address - Phone:317-996-3391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011298A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental