Healthcare Provider Details

I. General information

NPI: 1588703250
Provider Name (Legal Business Name): ASSOCIATED DENTISTS OF NORTHWEST INDIANA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WEST LINCOLN HWY SUITE N
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

500 WEST LINCOLN HWY SUITE N
MERRILLVILLE IN
46410
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-6444
  • Fax: 219-755-4790
Mailing address:
  • Phone: 219-769-6444
  • Fax: 219-755-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12009309A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12008668A
License Number StateIN

VIII. Authorized Official

Name: MISS MATILDA PEREZ
Title or Position: OFFICE MANAGER PRESIDENT
Credential:
Phone: 219-769-6444