Healthcare Provider Details

I. General information

NPI: 1912067349
Provider Name (Legal Business Name): INDIANA UNIVERSITY NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BROADWAY
GARY IN
46408-1101
US

IV. Provider business mailing address

3400 BROADWAY
GARY IN
46408-1101
US

V. Phone/Fax

Practice location:
  • Phone: 219-980-6772
  • Fax:
Mailing address:
  • Phone: 219-980-6772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number0
License Number StateIN

VIII. Authorized Official

Name: MRS. CINDY ZAK
Title or Position: CLINIC MANAGER
Credential: CDA
Phone: 219-980-6772