Provider Demographics
NPI:1801102868
Name:RENSSELAER FAMILY DENITISTRY LLC
Entity type:Organization
Organization Name:RENSSELAER FAMILY DENITISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-866-4533
Mailing Address - Street 1:210 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-2620
Mailing Address - Country:US
Mailing Address - Phone:219-866-4533
Mailing Address - Fax:
Practice Address - Street 1:210 N FRONT ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2620
Practice Address - Country:US
Practice Address - Phone:219-866-4533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty