=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073353934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRABHU DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2024
-----------------------------------------------------
Last Update Date | 05/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4440 S US HIGHWAY 41
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47802-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-238-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70887
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44190-0887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, PAYOR STRATEGY
-----------------------------------------------------
Name | VALERIE HAMILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-410-5531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------