Provider Demographics
NPI:1912955832
Name:INDIANA TMJ TREATMENT CENTER
Entity Type:Organization
Organization Name:INDIANA TMJ TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-778-3332
Mailing Address - Street 1:210 EAST WATER STREET
Mailing Address - Street 2:P.O. BOX 206
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-0206
Mailing Address - Country:US
Mailing Address - Phone:765-778-3332
Mailing Address - Fax:765-778-4860
Practice Address - Street 1:210 EAST WATER STREET
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-0206
Practice Address - Country:US
Practice Address - Phone:765-778-3332
Practice Address - Fax:765-778-4860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000196290OtherBLUE CROSS AND BLUE SHIEL
IN000000196290OtherBLUE CROSS AND BLUE SHIEL
IN=========-001Medicare UPIN