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General NPI Number Information
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NPI Number | 1770965717
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Entity Type | Organization
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Legal Business Name | GENTLE DENTAL
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Dates
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Enumeration Date | 06/26/2015
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Last Update Date | 06/26/2015
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Provider Practice Location Address
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Address Line | 3929 E 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5554
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Country | US
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Telephone | 812-339-7371
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Fax |
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Provider Business Mailing Address
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Address Line | 3929 E 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5554
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Country | US
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Telephone | 812-339-7371
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RHETT THARP
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Credential |
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Telephone | 812-339-7371
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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 | 8153
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License Number State | IN
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