Provider Demographics
NPI:1760559082
Name:DECATUR DENTAL SERVICES
Entity type:Organization
Organization Name:DECATUR DENTAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-368-7500
Mailing Address - Street 1:447 E LINE ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IN
Mailing Address - Zip Code:46740-8936
Mailing Address - Country:US
Mailing Address - Phone:260-368-7500
Mailing Address - Fax:
Practice Address - Street 1:447 E LINE ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IN
Practice Address - Zip Code:46740-8936
Practice Address - Country:US
Practice Address - Phone:260-368-7500
Practice Address - Fax:260-368-7167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120104121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100146810Medicaid
IN200355500Medicaid
IN300080654Medicaid