Provider Demographics
NPI:1881311736
Name:REGION DENTAL GROUP LLC
Entity type:Organization
Organization Name:REGION DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AJMAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WARDAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-225-6666
Mailing Address - Street 1:713 US HIGHWAY 41 STE A
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-1798
Mailing Address - Country:US
Mailing Address - Phone:219-227-8694
Mailing Address - Fax:219-266-5894
Practice Address - Street 1:713 US HIGHWAY 41 STE A
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1798
Practice Address - Country:US
Practice Address - Phone:219-227-8694
Practice Address - Fax:219-266-5894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1588793913OtherDENTAL