MEDICARE: DETAILED DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12011020	IN

General Provider Information

NPI Number	:	1215267661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DETAILED DENTAL

Provider Business Mailing Address
First Line	:	13963 MORSE ST
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	13963 MORSE ST
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-2400
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTINE GUDAS
Credential	:
Telephone Number	:	219-374-2400

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	01/07/2010

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Directions to “DETAILED DENTAL ” Practice Location

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