Healthcare Provider Details

I. General information

NPI: 1689122491
Provider Name (Legal Business Name): PLYMOUTH 20/20 DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 N MICHIGAN ST
PLYMOUTH IN
46563-1119
US

IV. Provider business mailing address

1409 N MICHIGAN ST
PLYMOUTH IN
46563-1119
US

V. Phone/Fax

Practice location:
  • Phone: 574-936-8787
  • Fax:
Mailing address:
  • Phone: 574-936-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD I PROKES
Title or Position: CHIEF FINANCIAL OFFICER
Credential: DDS
Phone: 317-601-6010