Provider Demographics
NPI:1356753230
Name:MARSHALL COUNTY FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:MARSHALL COUNTY FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-532-0011
Mailing Address - Street 1:125 S STEWART ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1829
Mailing Address - Country:US
Mailing Address - Phone:574-645-3037
Mailing Address - Fax:
Practice Address - Street 1:125 S STEWART ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1829
Practice Address - Country:US
Practice Address - Phone:574-645-3037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200091260A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1790909000Medicaid