1366001679 NPI number — BONTRAGER FAMILY DENTISTRY LLC

Table of content: JENNIFER LYNN ERDELYI NURSE PRACTITIONER (NPI 1336491422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366001679 NPI number — BONTRAGER FAMILY DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BONTRAGER FAMILY DENTISTRY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366001679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 183
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STROH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46789-0183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-580-5246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 S DETROIT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46761-2314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-463-2111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BONTRAGER
Authorized Official First Name:
KALYSSA
Authorized Official Middle Name:
MAE
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
260-580-5246

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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