| NPI | 1992506141 |
|---|---|
| Former Legal Business Name | GREEN LAKE COSMETIC DENTISTRY |
| Entity Type | Organization |
| Authorized Contact | CHERRYL SUE ELLISON Dentist Owner 812-272-4602 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2025-03-24 |
| Last Update Date | 2025-03-24 |