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General NPI Number Information
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NPI Number | 1649676354
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Entity Type | Organization
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Legal Business Name | CHALLGREN DENTISTRY PC
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Dates
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Enumeration Date | 11/06/2014
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Last Update Date | 11/06/2014
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Provider Practice Location Address
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Address Line | 170 PROFESSIONAL CT
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City | LAFAYETTE
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State | IN
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Zip | 47905-5153
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Country | US
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Telephone | 765-446-9606
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Fax | 765-446-9699
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Provider Business Mailing Address
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Address Line | 170 PROFESSIONAL CT
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City | LAFAYETTE
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State | IN
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Zip | 47905-5153
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Country | US
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Telephone | 765-446-9606
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Fax | 765-446-9699
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Authorized Official
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Title or Position | PRESIDENT
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Name | ERIK CHALLGREN
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Credential | DDS
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Telephone | 765-446-9606
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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 | 54001793A
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License Number State | IN
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