Provider Demographics
NPI:1538184460
Name:THE DENTAL CENTER OF SOUTH BEND LLC
Entity type:Organization
Organization Name:THE DENTAL CENTER OF SOUTH BEND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTALDIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MDS
Authorized Official - Phone:574-245-7501
Mailing Address - Street 1:1005 E LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2818
Mailing Address - Country:US
Mailing Address - Phone:574-245-7501
Mailing Address - Fax:574-245-7502
Practice Address - Street 1:1005 E LASALLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2818
Practice Address - Country:US
Practice Address - Phone:574-245-7501
Practice Address - Fax:574-245-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120159611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty