MEDICARE: MICHIANA FAMILY DENTAL 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	122300000X	Dentist

General Provider Information

NPI Number	:	1467946467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIANA FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	3575 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-6092
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3575 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-6092
Country	:	US
Telephone Number	:	203-215-4687
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SRINIVAS R DURSHANAPALLI
Credential	:	DDS
Telephone Number	:	203-215-4687

Provider Enumeration Date	:	06/22/2018
Last Update Date	:	09/17/2020

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Directions to “MICHIANA FAMILY DENTAL LLC ” Practice Location

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