MEDICARE: CHESTERTON FAMILY 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1295219368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHESTERTON FAMILY DENTAL

Provider Business Mailing Address
First Line	:	751 E PORTER AVE STE 1
Second Line	:
City	:	CHESTERTON
State	:	IN
Zip	:	46304-9111
Country	:	US
Telephone Number	:	219-929-9289
Fax Number	:

Provider Business Practice Location Address
First Line	:	751 E PORTER AVE STE 1
Second Line	:
City	:	CHESTERTON
State	:	IN
Zip	:	46304-9111
Country	:	US
Telephone Number	:	219-929-9289
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MYSTIE PIETERS
Credential	:	DDS
Telephone Number	:	219-929-9289

Provider Enumeration Date	:	09/24/2018
Last Update Date	:	09/24/2018

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Directions to “CHESTERTON FAMILY DENTAL ” Practice Location

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