Provider Demographics
NPI:1952404337
Name:INDIANA DENTAL CLINIC PC
Entity type:Organization
Organization Name:INDIANA DENTAL CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-292-2366
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47220
Mailing Address - Country:US
Mailing Address - Phone:812-358-5950
Mailing Address - Fax:812-358-2062
Practice Address - Street 1:615 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:IN
Practice Address - Zip Code:47220
Practice Address - Country:US
Practice Address - Phone:812-358-5950
Practice Address - Fax:812-358-2062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty