Provider Demographics
NPI:1639291958
Name:PRITCHARD JASTREMSKI DENTAL ASSOC. LLC
Entity type:Organization
Organization Name:PRITCHARD JASTREMSKI DENTAL ASSOC. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:JASTREMSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-339-2811
Mailing Address - Street 1:1550 S LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5167
Mailing Address - Country:US
Mailing Address - Phone:812-339-2811
Mailing Address - Fax:812-961-0746
Practice Address - Street 1:1550 S LIBERTY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5167
Practice Address - Country:US
Practice Address - Phone:812-339-2811
Practice Address - Fax:812-961-0746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty