Provider Demographics
NPI:1477356806
Name:DECATUR DENTAL SERVICES, INC
Entity type:Organization
Organization Name:DECATUR DENTAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLCLASURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-468-7020
Mailing Address - Street 1:470 BENNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:IN
Mailing Address - Zip Code:46792-9273
Mailing Address - Country:US
Mailing Address - Phone:260-468-7020
Mailing Address - Fax:
Practice Address - Street 1:470 BENNETT DR STE C
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:IN
Practice Address - Zip Code:46792-9273
Practice Address - Country:US
Practice Address - Phone:260-468-7020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DECATUR DENTAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201376990Medicaid
IN201368560Medicaid