Healthcare Provider Details

I. General information

NPI: 1124735782
Provider Name (Legal Business Name): 96TH STREET FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 11/03/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7862 E 96TH ST
FISHERS IN
46037-9629
US

IV. Provider business mailing address

340 PARKVIEW DR
NEW CASTLE IN
47362-2945
US

V. Phone/Fax

Practice location:
  • Phone: 317-576-9393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MEGAN MUNCHEL
Title or Position: REGIONAL MANAGER
Credential:
Phone: 765-529-7616