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General NPI Number Information
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NPI Number | 1760762108
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Entity Type | Organization
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Legal Business Name | JEFFERSON DENTAL CENTER, INC.
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Dates
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Enumeration Date | 08/17/2011
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Last Update Date | 01/08/2021
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Provider Practice Location Address
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Address Line | 2628 E JEFFERSON BLVD
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City | SOUTH BEND
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State | IN
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Zip | 46615-2724
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Country | US
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Telephone | 574-233-7266
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Fax | 574-233-7560
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Provider Business Mailing Address
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Address Line | 2628 E JEFFERSON BLVD
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City | SOUTH BEND
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State | IN
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Zip | 46615-2724
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Country | US
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Telephone | 574-233-7266
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Fax | 574-233-7560
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Authorized Official
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Title or Position | SECRETARY
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Name | MR. MONT L. ANNIS
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Credential |
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Telephone | 574-233-7266
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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 | 12007912 A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 12009908 A
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License Number State | IN
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