Provider Demographics
NPI:1962875286
Name:ELKHART DENTAL CENTER PC
Entity type:Organization
Organization Name:ELKHART DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBARSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-522-0156
Mailing Address - Street 1:125 S NAPPANEE ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1967
Mailing Address - Country:US
Mailing Address - Phone:574-522-0156
Mailing Address - Fax:574-294-1407
Practice Address - Street 1:125 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1967
Practice Address - Country:US
Practice Address - Phone:574-522-0156
Practice Address - Fax:574-294-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009361122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7571180001Medicare NSC