Healthcare Provider Details

I. General information

NPI: 1912955832
Provider Name (Legal Business Name): INDIANA TMJ TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 EAST WATER STREET
PENDLETON IN
46064-0206
US

IV. Provider business mailing address

210 EAST WATER STREET P.O. BOX 206
PENDLETON IN
46064-0206
US

V. Phone/Fax

Practice location:
  • Phone: 765-778-3332
  • Fax: 765-778-4860
Mailing address:
  • Phone: 765-778-3332
  • Fax: 765-778-4860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7161
License Number StateIN

VIII. Authorized Official

Name: DR. KENNETH LAU
Title or Position: DOCTOR
Credential: D.D.S.
Phone: 765-778-3332