MEDICARE: RED BIRD DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1033686142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED BIRD DENTAL LLC

Provider Business Mailing Address
First Line	:	85 ARGONAUT STE 220
Second Line	:
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-4105
Country	:	US
Telephone Number	:	949-305-2253
Fax Number	:

Provider Business Practice Location Address
First Line	:	839 S DELAWARE ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46225-1782
Country	:	US
Telephone Number	:	949-305-2253
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TERRY MCCOOE
Credential	:	DDS
Telephone Number	:	949-305-2253

Provider Enumeration Date	:	10/26/2018
Last Update Date	:	10/26/2018

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Directions to “RED BIRD DENTAL LLC ” Practice Location

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