Provider Demographics
NPI:1730890716
Name:WEST MAIN FAMILY DENTAL
Entity type:Organization
Organization Name:WEST MAIN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-966-6802
Mailing Address - Street 1:1836 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3822
Mailing Address - Country:US
Mailing Address - Phone:765-966-6802
Mailing Address - Fax:765-966-6889
Practice Address - Street 1:1836 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3822
Practice Address - Country:US
Practice Address - Phone:765-966-6802
Practice Address - Fax:765-966-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty