Provider Demographics
NPI:1215275284
Name:ALLUSION DENTAL, INC
Entity type:Organization
Organization Name:ALLUSION DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-762-4266
Mailing Address - Street 1:2646 LOIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3500
Mailing Address - Country:US
Mailing Address - Phone:219-762-4266
Mailing Address - Fax:
Practice Address - Street 1:2646 LOIS ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3500
Practice Address - Country:US
Practice Address - Phone:219-762-4266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011254A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty