Provider Demographics
NPI:1972985539
Name:TRINITY DENTAL
Entity type:Organization
Organization Name:TRINITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-582-2607
Mailing Address - Street 1:900 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-2525
Mailing Address - Country:US
Mailing Address - Phone:260-582-2607
Mailing Address - Fax:260-494-1218
Practice Address - Street 1:900 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2025
Practice Address - Country:US
Practice Address - Phone:260-582-2607
Practice Address - Fax:260-494-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201025790Medicaid