Healthcare Provider Details

I. General information

NPI: 1265355432
Provider Name (Legal Business Name): MAIN STREET DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GRANDVIEW DR
SALEM IN
47167-1022
US

IV. Provider business mailing address

200 GRANDVIEW DR
SALEM IN
47167-1022
US

V. Phone/Fax

Practice location:
  • Phone: 812-404-1000
  • Fax:
Mailing address:
  • Phone: 812-404-1000
  • 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: KADE DUANE ROACH
Title or Position: DR./OWNER
Credential: DDS
Phone: 812-404-1000