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General NPI Number Information
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NPI Number | 1972124717
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Entity Type | Organization
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Legal Business Name | JEFFERSONVILLE COMMONS DENTAL
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Dates
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Enumeration Date | 05/04/2020
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Last Update Date | 05/04/2020
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Provider Practice Location Address
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Address Line | 1019 JEFFERSONVILLE COMMONS DRIVE
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City | JEFFERSONVILLE
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State | IN
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Zip | 47130
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Country | US
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Telephone | 812-302-3200
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Fax | 812-302-3222
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Provider Business Mailing Address
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Address Line | 1410 SPRING ST
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City | JEFFERSONVILLE
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State | IN
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Zip | 47130-3731
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Country | US
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Telephone | 502-718-1226
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MICHELLE ELIZABETH FAETH
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Credential |
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Telephone | 502-718-1226
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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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