Healthcare Provider Details

I. General information

NPI: 1578560058
Provider Name (Legal Business Name): LOUIS ROBERT SERTICH D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

303 W 89TH AVE E-2
MERRILLVILLE IN
46410-6294
US

IV. Provider business mailing address

303 W 89TH AVE E-2
MERRILLVILLE IN
46410-6294
US

V. Phone/Fax

Practice location:
  • Phone: 219-755-0045
  • Fax: 219-755-0153
Mailing address:
  • Phone: 219-755-0045
  • Fax: 219-755-0153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008142
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: