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General NPI Number Information
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NPI Number | 1477176253
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Entity Type | Organization
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Legal Business Name | MY RIVERTOWN DENTIST LLC
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Dates
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Enumeration Date | 05/27/2020
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Last Update Date | 07/08/2020
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Provider Practice Location Address
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Address Line | 2513 MICHIGAN RD
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City | MADISON
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State | IN
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Zip | 47250-2422
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Country | US
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Telephone | 812-273-2388
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Fax |
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Provider Business Mailing Address
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Address Line | 2513 MICHIGAN RD
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City | MADISON
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State | IN
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Zip | 47250-2422
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Country | US
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Telephone | 812-273-2388
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ASHLEY LEE
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Credential |
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Telephone | 812-273-2388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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