=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215267661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DETAILED DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2010
-----------------------------------------------------
Last Update Date | 01/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13963 MORSE ST
-----------------------------------------------------
City | CEDAR LAKE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46303-9639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-374-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13963 MORSE ST
-----------------------------------------------------
City | CEDAR LAKE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46303-9639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-374-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTINE GUDAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-374-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12011020
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------