Provider Demographics
NPI:1841334125
Name:CELIS, LORRAINE JOSEPHINE (DDS)
Entity type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:JOSEPHINE
Last Name:CELIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2724
Mailing Address - Country:US
Mailing Address - Phone:574-233-7266
Mailing Address - Fax:574-233-7560
Practice Address - Street 1:2628 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2724
Practice Address - Country:US
Practice Address - Phone:574-233-7266
Practice Address - Fax:574-233-7560
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009908A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice