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General NPI Number Information
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NPI Number | 1972119030
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Entity Type | Organization
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Legal Business Name | ORA NW INDIANA, LLC
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Dates
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Enumeration Date | 09/23/2020
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Last Update Date | 09/23/2020
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Provider Practice Location Address
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Address Line | 10705 RANDOLPH ST
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City | CROWN POINT
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State | IN
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Zip | 46307-7615
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Country | US
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Telephone | 219-779-9114
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Fax |
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Provider Business Mailing Address
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Address Line | 10705 RANDOLPH ST
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City | CROWN POINT
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State | IN
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Zip | 46307-7615
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP
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Name | DANIEL MCGONIGLE
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Credential |
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Telephone | 708-906-4236
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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 |
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License Number State |
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