1245752534 NPI number — FAMILIA DENTAL INDIANAPOLIS AVONDALE, LLC

Table of content: (NPI 1245752534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245752534 NPI number — FAMILIA DENTAL INDIANAPOLIS AVONDALE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILIA DENTAL INDIANAPOLIS AVONDALE, LLC
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:
1245752534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 E ALGONQUIN RD STE 610
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHAUMBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60173-4166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-988-4066
Provider Business Mailing Address Fax Number:
847-496-4850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2940 E 38TH ST STE GHI
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46218-1217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-988-4066
Provider Business Practice Location Address Fax Number:
847-496-4850
Provider Enumeration Date:
07/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
CREDENTIALING PAYER RELATIONS MGR
Authorized Official Telephone Number:
847-453-7396

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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