Provider Demographics
NPI:1235003385
Name:JET DENTAL OF INDIANA, LLC
Entity type:Organization
Organization Name:JET DENTAL OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-240-1477
Mailing Address - Street 1:1005 E LASALLE AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2818
Mailing Address - Country:US
Mailing Address - Phone:801-430-9262
Mailing Address - Fax:
Practice Address - Street 1:1005 E LASALLE AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2818
Practice Address - Country:US
Practice Address - Phone:801-430-9262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JET MANAGEMENT SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty