Healthcare Provider Details

I. General information

NPI: 1114298064
Provider Name (Legal Business Name): MICHELLE ENJILIAN D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 DENTAL DR
BEDFORD IN
47421-3574
US

IV. Provider business mailing address

4236 E CAMBRIDGE DR
BLOOMINGTON IN
47408-3107
US

V. Phone/Fax

Practice location:
  • Phone: 812-275-7112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011760A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: