MEDICARE: DR. CARLO C LO DDS

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12009621A	IN

General Provider Information

NPI Number	:	1417991639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLO C LO DDS

Provider Business Mailing Address
First Line	:	3955 EAGLE CREEK PARKWAY, SUITE E
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254
Country	:	US
Telephone Number	:	317-291-2848
Fax Number	:

Provider Business Practice Location Address
First Line	:	3955 EAGLE CREEK PARKWAY, SUITE E
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254
Country	:	US
Telephone Number	:	317-291-2848
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/08/2007

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