Provider Demographics
NPI:1295940518
Name:THE DENTAL CENTER OF MISHAWAKA PC
Entity type:Organization
Organization Name:THE DENTAL CENTER OF MISHAWAKA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NUKES
Authorized Official - Suffix:
Authorized Official - Credentials:CREDENTIALING MGR
Authorized Official - Phone:574-245-7503
Mailing Address - Street 1:112 IRONWORKS AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2057
Mailing Address - Country:US
Mailing Address - Phone:574-255-4964
Mailing Address - Fax:
Practice Address - Street 1:112 IRONWORKS AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2057
Practice Address - Country:US
Practice Address - Phone:574-255-4964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120081181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty