MEDICARE: WASHINGTON STREET DENTISTRY INC.

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	122300000X	Dentist

General Provider Information

NPI Number	:	1225286099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON STREET DENTISTRY INC.

Provider Business Mailing Address
First Line	:	10935 E WASHINGTON ST
Second Line	:	SUITE A
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-3181
Country	:	US
Telephone Number	:	317-890-4435
Fax Number	:	317-890-4460

Provider Business Practice Location Address
First Line	:	10935 E WASHINGTON ST
Second Line	:	SUITE A
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-3181
Country	:	US
Telephone Number	:	317-890-4435
Fax Number	:	317-890-4460

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. MATTHEW E CHURCH
Credential	:	D.M.D.
Telephone Number	:	317-336-6723

Provider Enumeration Date	:	09/04/2008
Last Update Date	:	02/05/2013

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