MEDICARE: BLOOMINGTON DENTAL GROUP

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	12010765	IN

General Provider Information

NPI Number	:	1770535916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMINGTON DENTAL GROUP

Provider Business Mailing Address
First Line	:	1600 W BLOOMFIELD RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-2054
Country	:	US
Telephone Number	:	812-323-1530
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 W BLOOMFIELD RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-2054
Country	:	US
Telephone Number	:	812-323-1530
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RYAN D TSCHETTER
Credential	:	D.D.S.
Telephone Number	:	812-323-1530

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	08/22/2020

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