Organization
JEFFERSON DENTAL CENTER, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MONT L. ANNIS (SECRETARY)
(574) 233-7266
Entity
Organization
Contact information
Practice address
2628 E JEFFERSON BLVD, SOUTH BEND, IN 46615-2724
(574) 233-7266
(574) 233-7560
Mailing address
2628 E JEFFERSON BLVD, SOUTH BEND, IN 46615-2724
(574) 233-7266
(574) 233-7560
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
12007912 A
IN
261QD0000X
Dental Clinic/Center
Primary
12009908 A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100222700A
—
IN
05
—
200496100A
—
IN
Enumeration date
08/17/2011
Last updated
01/08/2021
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