Provider Demographics
NPI:1699173070
Name:GREENCASTLE 20/20 DENTAL, LLC
Entity type:Organization
Organization Name:GREENCASTLE 20/20 DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:I
Authorized Official - Last Name:PROKES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-727-1534
Mailing Address - Street 1:819 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1691
Mailing Address - Country:US
Mailing Address - Phone:765-653-5501
Mailing Address - Fax:
Practice Address - Street 1:819 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1691
Practice Address - Country:US
Practice Address - Phone:765-653-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:20/20 DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011722A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty