MEDICARE: CENTRAL INDIANA PERIODONTAL ASSOCIATES,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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1437333150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL INDIANA PERIODONTAL ASSOCIATES,LLC

Provider Business Mailing Address
First Line	:	2840 N HIGH SCHOOL RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-4724
Country	:	US
Telephone Number	:	317-299-4731
Fax Number	:	317-329-5054

Provider Business Practice Location Address
First Line	:	2840 N HIGH SCHOOL RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-4724
Country	:	US
Telephone Number	:	317-299-4731
Fax Number	:	317-329-5054

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	DR. DANIEL GOMES
Credential	:	DDS, MSD
Telephone Number	:	317-299-4731

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	12/18/2007

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