Healthcare Provider Details

I. General information

NPI: 1003104043
Provider Name (Legal Business Name): LOULY DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 E WASHINGTON STREET
INDIANAPOLIS IN
46229-2828
US

IV. Provider business mailing address

11530 E WASHINGTON STREET
INDIANAPOLIS IN
46229-2828
US

V. Phone/Fax

Practice location:
  • Phone: 317-869-0000
  • Fax: 317-869-0233
Mailing address:
  • Phone: 317-869-0000
  • Fax: 317-869-0233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number12009247A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. AMMAR C. LOULY
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-869-0000