Provider Demographics
NPI:1902154248
Name:SOUTHWAY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SOUTHWAY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUKSAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-896-9857
Mailing Address - Street 1:3745 S. MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-5756
Mailing Address - Country:US
Mailing Address - Phone:765-896-9857
Mailing Address - Fax:
Practice Address - Street 1:3745 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-5756
Practice Address - Country:US
Practice Address - Phone:765-896-9857
Practice Address - Fax:765-896-9937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009906A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty