Basic Information
Provider Information
NPI: 1659394963
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SERAFIN
FirstName: ANDREW
MiddleName: J
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1011 MICHIGAN AVE
Address2:  
City: LAPORTE
State: IN
PostalCode: 46350
CountryCode: US
TelephoneNumber: 2193624414
FaxNumber: 2193253550
Practice Location
Address1: 1011 MICHIGAN AVE
Address2:  
City: LAPORTE
State: IN
PostalCode: 46350
CountryCode: US
TelephoneNumber: 2193624414
FaxNumber: 2193253550
Other Information
ProviderEnumerationDate: 07/26/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X12006531INY Dental ProvidersDentistGeneral Practice

No ID Information.


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