Provider Demographics
NPI:1770696486
Name:THE DENTURE PLACE, INC.
Entity type:Organization
Organization Name:THE DENTURE PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-967-4425
Mailing Address - Street 1:1860 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IN
Mailing Address - Zip Code:46929-1446
Mailing Address - Country:US
Mailing Address - Phone:574-967-4425
Mailing Address - Fax:574-967-4400
Practice Address - Street 1:5 EXCUTIVE DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-447-2322
Practice Address - Fax:765-447-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN79431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty