| Organization Name: | MONROVIA DENTAL CLINIC, LLC |
| NPI Number: | 1134401144 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARK SANFORD (MEMBER) |
| Mailing Address: | 253 W Main St Monrovia |
| State: | IN US |
| Postal Code: | 461579567 |
| Phone Number: | 3179963391 |
| Fax Number: | |
| NPI Enumeration Date: | 09/15/2011 |
| NPI Last Update Date: | 09/15/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 12011298A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |