Provider Demographics
NPI:1720658040
Name:ADVANCE DENTURES OF MICHIANA
Entity Type:Organization
Organization Name:ADVANCE DENTURES OF MICHIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMELIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-855-1364
Mailing Address - Street 1:311 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8049
Mailing Address - Country:US
Mailing Address - Phone:574-855-1364
Mailing Address - Fax:574-314-5238
Practice Address - Street 1:311 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8049
Practice Address - Country:US
Practice Address - Phone:574-855-1364
Practice Address - Fax:574-314-5238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty