Healthcare Provider Details

I. General information

NPI: 1063657187
Provider Name (Legal Business Name): FORTVILLE FAMILY DENISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 S MAIN ST
FORTVILLE IN
46040-1315
US

IV. Provider business mailing address

14 S MAIN ST
FORTVILLE IN
46040-1315
US

V. Phone/Fax

Practice location:
  • Phone: 317-485-5251
  • Fax:
Mailing address:
  • Phone: 317-485-5251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12008802B
License Number StateIN

VIII. Authorized Official

Name: DR. BRADLEY PAUL LACONI
Title or Position: OWNER
Credential:
Phone: 317-485-5251