NPIMap

Organization Active NPI

Jefferson Dental Center, Inc.

  • Dental Clinic/Center
  • South Bend, IN
National Provider Identifier
1760762108
Registry record updated Jan 8, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
License
12009908 A Issued in IN
Legal business name
JEFFERSON DENTAL CENTER, INC.
Practice address
2628 E Jefferson Blvd
South Bend, IN 46615-2724
Phone
(574) 233-7266
Fax
(574) 233-7560
NPI assigned
Aug 17, 2011
Last updated
Jan 8, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 8, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Mont L. Annis
Title
Secretary
Phone
(574) 233-7266

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X 12007912 A IN
Dental Clinic/Center 261QD0000X 12009908 A IN Primary

Addresses

Primary practice location

2628 E Jefferson Blvd
South Bend, IN 46615-2724

Mailing address

2628 E Jefferson Blvd
South Bend, IN 46615-2724
Phone (574) 233-7266

Other identifiers 2

IdentifierTypeStateIssuer
100222700AMedicaidIN
200496100AMedicaidIN

National Provider Directory

National Provider Directory

Locations

2628 E Jefferson Blvd
South Bend, IN 46615
Phone (574) 233-7266

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1313539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1610064000000",
    "number": "1760762108",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2628 E JEFFERSON BLVD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466152724",
            "telephone_number": "574-233-7266",
            "fax_number": "574-233-7560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2628 E JEFFERSON BLVD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466152724",
            "telephone_number": "574-233-7266",
            "fax_number": "574-233-7560"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON DENTAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-08-17",
        "last_updated": "2021-01-08",
        "certification_date": "2021-01-08",
        "status": "A",
        "authorized_official_last_name": "ANNIS",
        "authorized_official_first_name": "MONT",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "574-233-7266",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "IN",
            "license": "12007912 A",
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "IN",
            "license": "12009908 A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100222700A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200496100A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Bend, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.