Provider Demographics
NPI:1699115253
Name:CROWN HILL DENTISTRY LLC
Entity type:Organization
Organization Name:CROWN HILL DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-832-7741
Mailing Address - Street 1:1792 E STATE ROAD 163
Mailing Address - Street 2:PO BOX 408
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-7327
Mailing Address - Country:US
Mailing Address - Phone:765-832-7741
Mailing Address - Fax:765-832-7743
Practice Address - Street 1:1792 E STATE HIGHWAY 163
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-0160
Practice Address - Country:US
Practice Address - Phone:765-832-7741
Practice Address - Fax:765-832-7743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006928A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1002436440AMedicaid