MEDICARE: INDY SOUTH 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	:	1205527868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDY SOUTH DENTAL LLC

Provider Business Mailing Address
First Line	:	333 MASSACHUSETTS AVE UNIT 401
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-2039
Country	:	US
Telephone Number	:	317-525-7398
Fax Number	:

Provider Business Practice Location Address
First Line	:	6815 S EMERSON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46237-3361
Country	:	US
Telephone Number	:	317-525-7398
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. ANKIT PATEL
Credential	:	DMD
Telephone Number	:	317-525-7398

Provider Enumeration Date	:	05/16/2023
Last Update Date	:	05/16/2023

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