MEDICARE: NORTHSIDE ENDODONTICS, 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	1223E0200X	Endodontics	54000837A	IN

General Provider Information

NPI Number	:	1730345646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE ENDODONTICS, PC

Provider Business Mailing Address
First Line	:	1010 E 86TH ST
Second Line	:	SUITE 15
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1868
Country	:	US
Telephone Number	:	317-844-3396
Fax Number	:	317-844-4776

Provider Business Practice Location Address
First Line	:	1010 E 86TH ST
Second Line	:	SUITE 15
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1868
Country	:	US
Telephone Number	:	317-844-3396
Fax Number	:	317-844-4776

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN H SLAVENS
Credential	:	DDS, MSD
Telephone Number	:	317-844-3396

Provider Enumeration Date	:	07/30/2008
Last Update Date	:	07/30/2008

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