Healthcare Provider Details

I. General information

NPI: 1477753473
Provider Name (Legal Business Name): ANA H VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9126 TECHNOLOGY LANE SUITE 100
FISHERS IN
46038
US

IV. Provider business mailing address

9126 TECHNOLOGY LN SUITE 100
FISHERS IN
46038-3064
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: