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General NPI Number Information
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NPI Number | 1437669967
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Entity Type | Organization
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Legal Business Name | SALEM FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 10/11/2017
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Last Update Date | 10/11/2017
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Provider Practice Location Address
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Address Line | 100 N HARRISON ST
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City | SALEM
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State | IN
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Zip | 47167-1426
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Country | US
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Telephone | 812-883-5804
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Fax | 812-883-0603
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Provider Business Mailing Address
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Address Line | 2126 N STATE ROAD 135
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City | SALEM
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State | IN
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Zip | 47167-6005
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Country | US
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Telephone | 821-620-1633
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. TRICIA K WHEELER
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Credential | DMD
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Telephone | 812-883-5804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 12010386
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License Number State | IN
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