Provider Demographics
NPI:1982433819
Name:NORTHWEST PEDIATRIC DENTAL LLC
Entity type:Organization
Organization Name:NORTHWEST PEDIATRIC DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MITSOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-440-1710
Mailing Address - Street 1:8217 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:ST. JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373
Mailing Address - Country:US
Mailing Address - Phone:219-440-1710
Mailing Address - Fax:
Practice Address - Street 1:8217 WICKER AVE
Practice Address - Street 2:
Practice Address - City:ST. JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373
Practice Address - Country:US
Practice Address - Phone:219-440-1710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty