Provider Demographics
NPI:1144696600
Name:JEFFERSONVILLE FAMILY DENTAL, PC
Entity type:Organization
Organization Name:JEFFERSONVILLE FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD TERRELL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:812-288-8131
Mailing Address - Street 1:900 SPRING ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3675
Mailing Address - Country:US
Mailing Address - Phone:812-288-8131
Mailing Address - Fax:812-280-7184
Practice Address - Street 1:900 SPRING ST
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3675
Practice Address - Country:US
Practice Address - Phone:812-288-8131
Practice Address - Fax:812-280-7184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011200A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200911820Medicaid