Healthcare Provider Details

I. General information

NPI: 1912405762
Provider Name (Legal Business Name): WESTFIELD DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E MAIN ST
WESTFIELD IN
46074-9395
US

IV. Provider business mailing address

522 E JASPER ST
PARIS IL
61944-2437
US

V. Phone/Fax

Practice location:
  • Phone: 317-896-5353
  • Fax:
Mailing address:
  • Phone: 217-463-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BLAKE WESTRA
Title or Position: OWNER
Credential: DMD
Phone: 314-660-7780