| Jefferson Dental Center, Inc. | |
|
2628 E Jefferson Blvd South Bend IN 46615-2724 | |
| (574) 233-7266 | |
| (574) 233-7560 |
| Full Name | Jefferson Dental Center, Inc. |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 2628 E Jefferson Blvd, South Bend, Indiana |
| Authorized Official Name and Position | Mont L. Annis (SECRETARY) |
| Authorized Official Contact | 5742337266 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Jefferson Dental Center, Inc. 2628 E Jefferson Blvd South Bend IN 46615-2724 Ph: (574) 233-7266 | Jefferson Dental Center, Inc. 2628 E Jefferson Blvd South Bend IN 46615-2724 Ph: (574) 233-7266 |
| NPI Number | 1760762108 |
|---|---|
| Provider Enumeration Date | 08/17/2011 |
| Last Update Date | 01/08/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760762108 | NPI | - | NPPES |
| 100222700A | Medicaid | IN | |
| 200496100A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 12009908 A (Indiana) | Primary |
| 261QD0000X | Clinic/center - Dental | 12007912 A (Indiana) | Secondary |
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