1558785709 NPI number — PLAINFIELD DENTAL

Table of content: (NPI 1558785709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558785709 NPI number — PLAINFIELD DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLAINFIELD DENTAL
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:
1558785709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
824 EDWARDS DR
Provider Second Line Business Mailing Address:
UNIT 124
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46168-2791
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-268-4593
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 EDWARDS DR
Provider Second Line Business Practice Location Address:
UNIT 124
Provider Business Practice Location Address City Name:
PLAINFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46168-2791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-268-4593
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KINGSEED
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
260-318-3151

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  12011426A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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