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General NPI Number Information
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NPI Number | 1952310039
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Entity Type | Organization
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Legal Business Name | CRYSTAL VALLEY FAMILY DENTISTRY, P.C.
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Dates
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Enumeration Date | 08/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1004 SPRING ARBOR DR
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City | MIDDLEBURY
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State | IN
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Zip | 46540-9493
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Country | US
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Telephone | 574-825-4040
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Fax | 574-825-3377
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Provider Business Mailing Address
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Address Line | 1004 SPRING ARBOR DR
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City | MIDDLEBURY
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State | IN
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Zip | 46540-9493
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Country | US
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Telephone | 574-825-4040
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Fax | 574-825-3377
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAVID P REGAN
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Credential | DDS
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Telephone | 574-825-4040
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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 | 12010372A
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License Number State | IN
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