Healthcare Provider Details

I. General information

NPI: 1497446033
Provider Name (Legal Business Name): OP ORTHODONTICS OF INDIANA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 DOUGLAS RD
SOUTH BEND IN
46635-1788
US

IV. Provider business mailing address

5300 PATTERSON AVE SE STE 110
GRAND RAPIDS MI
49512-5663
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-7444
  • Fax:
Mailing address:
  • Phone: 616-737-9401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STACY POPE
Title or Position: PROJECT MANAGER
Credential:
Phone: 616-283-8867