# MISHAWAKA DENTAL LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

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

## Provider details

- **NPI number:** 1730624529
- **Authorized official:** HEATHER KRAUSHAAR (PSR)
- **Authorized official phone:** (315) 454-6000

## Contact information

- **Practice address:** 4170 GRAPE RD, MISHAWAKA, IN 46545-2610
- **Practice address phone:** (574) 272-4200
- **Mailing address:** PO BOX 3189, SYRACUSE, NY 13220-3189

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 12012619A | IN | Yes |

## Other

- **Enumeration date:** 01/03/2017
- **Last updated:** 01/03/2017