1003947599 NPI number — UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES

Table of content: (NPI 1003947599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003947599 NPI number — UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003947599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 RILEY HOSPITAL DR
Provider Second Line Business Mailing Address:
ROC - SUITE 4205
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46202-5109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-944-9604
Provider Business Mailing Address Fax Number:
317-948-0760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 RILEY HOSPITAL DR
Provider Second Line Business Practice Location Address:
ROC - SUITE 4205
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-944-9604
Provider Business Practice Location Address Fax Number:
317-948-0760
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-944-9604

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100061940 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103337 . This is a "CHILDREN SPECIAL HEALTH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100176300 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200331160 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200515490 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003587 . This is a "GROUP ID PRIV. INSUR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100087220 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100440160 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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