Healthcare Provider Details

I. General information

NPI: 1386203693
Provider Name (Legal Business Name): KALYSSA MAE BONTRAGER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KALEY MAE BONTRAGER DDS

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S DETROIT ST
LAGRANGE IN
46761-2314
US

IV. Provider business mailing address

PO BOX 183
STROH IN
46789-0183
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-2111
  • Fax:
Mailing address:
  • Phone: 260-580-5246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12013143A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: