Provider Demographics
NPI:1194265553
Name:IRELAND PARK DENTISTRY
Entity type:Organization
Organization Name:IRELAND PARK DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:574-291-8022
Mailing Address - Street 1:1902 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2863
Mailing Address - Country:US
Mailing Address - Phone:574-291-8022
Mailing Address - Fax:574-291-7868
Practice Address - Street 1:1902 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2863
Practice Address - Country:US
Practice Address - Phone:574-291-8022
Practice Address - Fax:574-291-7868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011066A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty