Healthcare Provider Details

I. General information

NPI: 1760616114
Provider Name (Legal Business Name): EASTERN INDIANA PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 N GRAND AVE
CONNERSVILLE IN
47331-2015
US

IV. Provider business mailing address

1840 SUMMERLAKES CT
CARMEL IN
46032-9392
US

V. Phone/Fax

Practice location:
  • Phone: 765-825-2051
  • Fax:
Mailing address:
  • Phone: 317-566-8183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12006522B
License Number StateIN

VIII. Authorized Official

Name: DR. CHARLES POLAND III
Title or Position: MEMBER
Credential: DDS
Phone: 317-566-8183