MEDICARE: BLOOMINGTON SOUTHSIDE DENTAL CARE. LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1114439189	OTHER	IN	NAREY NPI
2	1720370059	OTHER	IN	PERSONAL NPI

General Provider Information

NPI Number	:	1437890290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMINGTON SOUTHSIDE DENTAL CARE. LLC

Provider Business Mailing Address
First Line	:	191 W GORDON PIKE
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-4518
Country	:	US
Telephone Number	:	812-824-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 W GORDON PIKE
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-4518
Country	:	US
Telephone Number	:	812-824-4444
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JILL RENE REITMEYER
Credential	:	DDS
Telephone Number	:	812-824-4444

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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