Provider Demographics
NPI:1316713290
Name:DENTAL 360 DYER LLC
Entity type:Organization
Organization Name:DENTAL 360 DYER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IVANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-798-9382
Mailing Address - Street 1:890 RICHARD RD
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:890 RICHARD RD
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1779
Practice Address - Country:US
Practice Address - Phone:219-322-1326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty