Provider Demographics
NPI:1063880532
Name:GB WESTFIELD
Entity type:Organization
Organization Name:GB WESTFIELD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-662-0018
Mailing Address - Street 1:617 N RIVER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2648
Mailing Address - Country:US
Mailing Address - Phone:765-662-0018
Mailing Address - Fax:
Practice Address - Street 1:16407 SOUTHPARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8472
Practice Address - Country:US
Practice Address - Phone:317-867-1133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty