# DETAILED DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215267661
- **Authorized official:** CHRISTINE GUDAS (OWNER)
- **Authorized official phone:** (219) 374-2400

## Contact information

- **Practice address:** 13963 MORSE ST, CEDAR LAKE, IN 46303-9639
- **Practice address phone:** (219) 374-2400
- **Mailing address:** 13963 MORSE ST, CEDAR LAKE, IN 46303-9639
- **Mailing address phone:** (219) 374-2400

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 12011020 | IN | Yes |

## Other

- **Enumeration date:** 01/07/2010
- **Last updated:** 01/07/2010