Provider Demographics
NPI:1528118148
Name:ADVANCED DENTAL
Entity type:Organization
Organization Name:ADVANCED DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:IRMA
Authorized Official - Last Name:GAMBETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-923-3391
Mailing Address - Street 1:1801 ORIOLE DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3443
Mailing Address - Country:US
Mailing Address - Phone:219-923-3391
Mailing Address - Fax:219-365-5448
Practice Address - Street 1:15285 W 101ST AVE
Practice Address - Street 2:SUITE H
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-3035
Practice Address - Country:US
Practice Address - Phone:219-365-5420
Practice Address - Fax:219-365-5448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010023A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty