Provider Demographics
NPI:1811287519
Name:PLYMOUTH FAMILY DENTISTRY, INC
Entity type:Organization
Organization Name:PLYMOUTH FAMILY DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-396-0644
Mailing Address - Street 1:1400 N OAK DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-3403
Mailing Address - Country:US
Mailing Address - Phone:574-936-0644
Mailing Address - Fax:
Practice Address - Street 1:1400 N OAK DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-3403
Practice Address - Country:US
Practice Address - Phone:574-936-0644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty