Provider Demographics
NPI:1649676354
Name:CHALLGREN DENTISTRY PC
Entity type:Organization
Organization Name:CHALLGREN DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALLGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-446-9606
Mailing Address - Street 1:170 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5153
Mailing Address - Country:US
Mailing Address - Phone:765-446-9606
Mailing Address - Fax:765-446-9699
Practice Address - Street 1:170 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5153
Practice Address - Country:US
Practice Address - Phone:765-446-9606
Practice Address - Fax:765-446-9699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54001793A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty