Provider Demographics
NPI:1770965717
Name:GENTLE DENTAL
Entity type:Organization
Organization Name:GENTLE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:
Authorized Official - Last Name:THARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-339-7371
Mailing Address - Street 1:3929 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5554
Mailing Address - Country:US
Mailing Address - Phone:812-339-7371
Mailing Address - Fax:
Practice Address - Street 1:3929 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5554
Practice Address - Country:US
Practice Address - Phone:812-339-7371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8153261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942397567OtherNPI
IN100260280AMedicaid