MEDICARE: CVILLE 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1639870363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CVILLE DENTAL LLC

Provider Business Mailing Address
First Line	:	1950 INDIANAPOLIS RD
Second Line	:
City	:	CRAWFORDSVILLE
State	:	IN
Zip	:	47933-3135
Country	:	US
Telephone Number	:	765-364-1740
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 INDIANAPOLIS RD
Second Line	:
City	:	CRAWFORDSVILLE
State	:	IN
Zip	:	47933-3135
Country	:	US
Telephone Number	:	765-364-1740
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MARK SANFORD
Credential	:	DDS
Telephone Number	:	317-491-5095

Provider Enumeration Date	:	03/10/2023
Last Update Date	:	01/07/2025

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