Healthcare Provider Details

I. General information

NPI: 1295815835
Provider Name (Legal Business Name): FISHERS PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9124 TECHNOLOGY DR SUITE 100
FISHERS IN
46038-3064
US

IV. Provider business mailing address

9124 TECHNOLOGY DR SUITE 100
FISHERS IN
46038-3064
US

V. Phone/Fax

Practice location:
  • Phone: 317-598-9898
  • Fax: 317-596-9659
Mailing address:
  • Phone: 317-598-9898
  • Fax: 317-596-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12009305B
License Number StateIN

VIII. Authorized Official

Name: KERRI RUMMELL
Title or Position: FRONT OFFICE COORDINATOR
Credential:
Phone: 317-598-9898