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General NPI Number Information
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NPI Number | 1114016201
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Entity Type | Organization
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Legal Business Name | MARC J MEADOWS DDS PC
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 07/17/2008
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Provider Practice Location Address
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Address Line | 515 S WOODSCREST DR
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5524
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Country | US
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Telephone | 812-332-0866
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Fax |
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Provider Business Mailing Address
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Address Line | 515 S WOODSCREST DR
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5524
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Country | US
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Telephone | 812-332-0866
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | LISA MARIE MEADOWS
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Credential |
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Telephone | 812-332-0866
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12010415
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License Number State | IN
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