MEDICARE: CEDAR LAKE DENTAL CENTER, INC.

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	1223G0001X	General Practice Dentistry	54000250A	IN

General Provider Information

NPI Number	:	1326126871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR LAKE DENTAL CENTER, INC.

Provider Business Mailing Address
First Line	:	13955 MORSE ST
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-5591
Fax Number	:	219-662-2573

Provider Business Practice Location Address
First Line	:	13955 MORSE ST
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-5591
Fax Number	:	219-662-2573

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD DOUGLAS KAZWELL
Credential	:	D.D.S.
Telephone Number	:	219-374-5591

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2020

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