1669927786 NPI number — DENTAL SAFARI CO INDIANA, LLC

Table of content: (NPI 1669927786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669927786 NPI number — DENTAL SAFARI CO INDIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SAFARI CO INDIANA, 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:
1669927786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2314
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-993-8333
Provider Business Mailing Address Fax Number:
618-993-8335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1634 E NORTHFIELD DR., STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-993-8333
Provider Business Practice Location Address Fax Number:
618-993-8335
Provider Enumeration Date:
08/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MORLEY
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
618-559-6654

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201382420A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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