Provider Demographics
NPI:1063515914
Name:ELLETTSVILLE DENTAL CENTER, INC.
Entity type:Organization
Organization Name:ELLETTSVILLE DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:COMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-876-7330
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:ELLETTSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47429-0518
Mailing Address - Country:US
Mailing Address - Phone:812-876-7330
Mailing Address - Fax:812-876-7325
Practice Address - Street 1:5915 WEST HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:ELLETTSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47429-0518
Practice Address - Country:US
Practice Address - Phone:812-876-7330
Practice Address - Fax:812-876-7325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200348440AMedicaid