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857 S Auto Mall Rd Bloomington IN 47401-5447 | |
| (812) 332-2204 | |
| (821) 332-9095 |
| Full Name | |
|---|---|
| Speciality | Dentist - Oral And Maxillofacial Surgery |
| Location | 857 S Auto Mall Rd, Bloomington, Indiana |
| Authorized Official Name and Position | Timothy Devitt (OWNER) |
| Authorized Official Contact | 8123322204 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
857 S Auto Mall Rd Bloomington IN 47401-5447 Ph: (812) 332-2204 | 857 S Auto Mall Rd Bloomington IN 47401-5447 Ph: (812) 332-2204 |
| NPI Number | 1841505252 |
|---|---|
| Provider Enumeration Date | 08/10/2010 |
| Last Update Date | 08/10/2010 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841505252 | NPI | - | NPPES |
| 200809540A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | 0652A (Indiana) | Primary |
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