1912955832 NPI number — INDIANA TMJ TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912955832 NPI number — INDIANA TMJ TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA TMJ TREATMENT CENTER
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:
1912955832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 EAST WATER STREET
Provider Second Line Business Mailing Address:
P.O. BOX 206
Provider Business Mailing Address City Name:
PENDLETON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46064-0206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-778-3332
Provider Business Mailing Address Fax Number:
765-778-4860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 EAST WATER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46064-0206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-778-3332
Provider Business Practice Location Address Fax Number:
765-778-4860
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAU
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
765-778-3332

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  7161 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000196290 . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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