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General NPI Number Information
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NPI Number | 1740718980
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Entity Type | Organization
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Legal Business Name | ELWOOD FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 06/01/2017
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Last Update Date | 06/01/2017
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Provider Practice Location Address
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Address Line | 213 N 16TH ST
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City | ELWOOD
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State | IN
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Zip | 46036-1769
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Country | US
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Telephone | 765-552-7803
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Fax | 765-552-5106
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Provider Business Mailing Address
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Address Line | 16426 CHALET CIR
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City | WESTFIELD
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State | IN
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Zip | 46074-8781
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Country | US
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Telephone | 317-756-7125
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MR. KEVIN LEFEVRE
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Credential |
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Telephone | 317-756-7125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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