Healthcare Provider Details

I. General information

NPI: 1174824122
Provider Name (Legal Business Name): UNITED DENTAL CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 119TH ST
WHITING IN
46394-1631
US

IV. Provider business mailing address

1332 119TH ST
WHITING IN
46394-1631
US

V. Phone/Fax

Practice location:
  • Phone: 219-659-4900
  • Fax:
Mailing address:
  • Phone: 219-659-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12009174
License Number StateIN

VIII. Authorized Official

Name: DR. KENNETH FRIED
Title or Position: PRESIDENT
Credential: DDS
Phone: 219-659-4900