MEDICARE: DENTISTRYONE OF INDIANA PC

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	1223P0221X	Pediatric Dentistry
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1205698818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTRYONE OF INDIANA PC

Provider Business Mailing Address
First Line	:	20 HIGHLAND AVE
Second Line	:
City	:	METUCHEN
State	:	NJ
Zip	:	08840-1949
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 SHELBY ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-1163
Country	:	US
Telephone Number	:	877-712-7875
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEREK WEIGAND
Credential	:
Telephone Number	:	877-712-7875

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	05/13/2025

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Directions to “DENTISTRYONE OF INDIANA PC ” Practice Location

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