Basic Information
| Provider Information | |||||||||
| NPI: | 1093122418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIRACLE LANE FAMILY DENTISTRY P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2332 MIRACLE LN | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595437 | ||||||||
| FaxNumber: | 5742595438 | ||||||||
| Practice Location | |||||||||
| Address1: | 2332 MIRACLE LN | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595437 | ||||||||
| FaxNumber: | 5742595438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERRITT-BROOKS | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3136104688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 54001789A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.