=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366854143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTLAND FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2014
-----------------------------------------------------
Last Update Date | 05/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 E LINCOLN ST
-----------------------------------------------------
City | KENTLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47951-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-474-5059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 E LINCOLN ST
-----------------------------------------------------
City | KENTLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47951-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-474-5059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE
-----------------------------------------------------
Name | DR. MELINDA SUE BODINE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 219-474-5059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1639581507
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------