MEDICARE: RIVER BEND DENTAL GROUP

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	1223G0001X	General Practice Dentistry	12009288	IN

General Provider Information

NPI Number	:	1881970424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER BEND DENTAL GROUP

Provider Business Mailing Address
First Line	:	1015 PROFESSIONAL BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-8010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 PROFESSIONAL BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-8010
Country	:	US
Telephone Number	:	812-437-1015
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	TARA DOUGHTY
Credential	:
Telephone Number	:	812-437-1015

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	10/27/2011

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