# JEFFERSON DENTAL CENTER, INC.

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

## Provider details

- **NPI number:** 1760762108
- **Authorized official:** MR. MONT L. ANNIS (SECRETARY)
- **Authorized official phone:** (574) 233-7266

## Contact information

- **Practice address:** 2628 E JEFFERSON BLVD, SOUTH BEND, IN 46615-2724
- **Practice address phone:** (574) 233-7266
- **Practice address fax:** (574) 233-7560
- **Mailing address:** 2628 E JEFFERSON BLVD, SOUTH BEND, IN 46615-2724
- **Mailing address phone:** (574) 233-7266
- **Mailing address fax:** (574) 233-7560

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | 12007912 A | IN | — |
| 261QD0000X | Dental Clinic/Center | 12009908 A | IN | Yes |

## Other

- **Enumeration date:** 08/17/2011
- **Last updated:** 01/08/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100222700A | — | IN |
| 05 | — | 200496100A | — | IN |