Organization
NORTHWEST PEDIATRIC DENTAL LLC
Active
Other names
Southwest Pediatric Dental
Organization subpart
No
Provider details
NPI number
Authorized official
JAMES R MITSOS (OWNER)
(219) 440-1710
Entity
Organization
Contact information
Practice address
8217 WICKER AVE, ST. JOHN, IN 46373
(219) 440-1710
Mailing address
8217 WICKER AVE, ST. JOHN, IN 46373
(219) 440-1710
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
—
—
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Enumeration date
07/30/2024
Last updated
10/03/2024
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