1487410551 NPI number — 8840 MICHIGAN ROAD DENTAL, LLC

Table of content: (NPI 1487410551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487410551 NPI number — 8840 MICHIGAN ROAD DENTAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
8840 MICHIGAN ROAD DENTAL, 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:
1487410551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12460 HORSHAM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-7289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8840 MICHIGAN RD STE 111
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:
46268-1440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-939-6377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2024

Additional Information

Authorized Official

Authorized Official Last Name:
STRATMAN
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
317-939-6377

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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