1144746314 NPI number — DENTAL SERVICES OF INDIANA, P.C.

Table of content: (NPI 1144746314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144746314 NPI number — DENTAL SERVICES OF INDIANA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SERVICES OF INDIANA, P.C.
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:
6
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:
1144746314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66207-4268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-428-1686
Provider Business Mailing Address Fax Number:
913-752-9116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
532 EAST 81ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-428-1686
Provider Business Practice Location Address Fax Number:
913-752-9116
Provider Enumeration Date:
08/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGER OF PROVIDER CREDENTIALING
Authorized Official Telephone Number:
913-428-1686

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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