MEDICARE: PERSONALIZED DENTAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8590	IN

General Provider Information

NPI Number	:	1306080734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERSONALIZED DENTAL CENTER

Provider Business Mailing Address
First Line	:	1411 S WOODLAND AVE STE F
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-7170
Country	:	US
Telephone Number	:	219-872-4151
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 S WOODLAND AVE STE F
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-7170
Country	:	US
Telephone Number	:	219-872-4151
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CINDY KIRBY
Credential	:	DDS
Telephone Number	:	219-678-0485

Provider Enumeration Date	:	04/29/2009
Last Update Date	:	04/29/2009

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Directions to “PERSONALIZED DENTAL CENTER ” Practice Location

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