MEDICARE: FAIRVIEW FAMILY 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	:	1184229809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRVIEW FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	2291 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-5727
Country	:	US
Telephone Number	:	317-926-5467
Fax Number	:	317-926-6022

Provider Business Practice Location Address
First Line	:	3195 W FAIRVIEW RD STE B
Second Line	:
City	:	GREENWOOD
State	:	IN
Zip	:	46142-8499
Country	:	US
Telephone Number	:	317-887-0888
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHEN TRAGER
Credential	:	DDS
Telephone Number	:	317-926-5467

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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