Healthcare Provider Details

I. General information

NPI: 1578568937
Provider Name (Legal Business Name): STANLEY C. JACHIMOWICZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/23/2006

III. Provider practice location address

13590B N MERIDIAN ST STE 105
CARMEL IN
46032-1409
US

IV. Provider business mailing address

13590B N MERIDIAN ST STE 105
CARMEL IN
46032-1409
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-7626
  • Fax: 317-844-3804
Mailing address:
  • Phone: 317-844-7626
  • Fax: 317-844-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12009721A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: