MEDICARE: FIELDS 20/20 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	1223G0001X	General Practice Dentistry	12008811A	IN

General Provider Information

NPI Number	:	1336572536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIELDS 20/20 DENTAL, LLC

Provider Business Mailing Address
First Line	:	6333 W THOMPSON RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46221-3619
Country	:	US
Telephone Number	:	317-856-5050
Fax Number	:	317-856-5091

Provider Business Practice Location Address
First Line	:	6333 W THOMPSON RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46221-3619
Country	:	US
Telephone Number	:	317-856-5050
Fax Number	:	317-856-5091

Authorized Official
Title or Position	:	D.D.S.
Name	:	DR. WILLIAM N MYERS
Credential	:	D.D.S.
Telephone Number	:	317-856-5050

Provider Enumeration Date	:	08/12/2013
Last Update Date	:	08/12/2013

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