MEDICARE: JP DENTAL - RICHMOND 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

General Provider Information

NPI Number	:	1992154587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JP DENTAL - RICHMOND LLC

Provider Business Mailing Address
First Line	:	894 SIM HODGIN PKWY
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1931
Country	:	US
Telephone Number	:	765-962-3713
Fax Number	:

Provider Business Practice Location Address
First Line	:	894 SIM HODGIN PKWY
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1931
Country	:	US
Telephone Number	:	765-962-3713
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN PASICZNYK
Credential	:	DDS
Telephone Number	:	317-818-7777

Provider Enumeration Date	:	06/06/2016
Last Update Date	:	06/06/2016

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