Provider Demographics
NPI:1104990233
Name:MAIN STREET FAMILY DENTISTRY
Entity type:Organization
Organization Name:MAIN STREET FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VANNATTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-839-5500
Mailing Address - Street 1:712 W MAIN STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-9403
Mailing Address - Country:US
Mailing Address - Phone:317-839-5550
Mailing Address - Fax:317-839-5509
Practice Address - Street 1:712 W MAIN STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-9403
Practice Address - Country:US
Practice Address - Phone:317-839-5550
Practice Address - Fax:317-839-5509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120098211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty