Healthcare Provider Details

I. General information

NPI: 1245435437
Provider Name (Legal Business Name): DENTAL SLEEP MEDICINE OF INDIANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 CASTLE CREEK PARKWAY NORTH DRIVE
INDIANAPOLIS IN
46250
US

IV. Provider business mailing address

5625 CASTLE CREEK PARKWAY NORTH DRIVE
INDIANAPOLIS IN
46250
US

V. Phone/Fax

Practice location:
  • Phone: 317-585-0005
  • Fax: 317-585-0006
Mailing address:
  • Phone: 317-585-0005
  • Fax: 317-585-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12006427
License Number StateIN

VIII. Authorized Official

Name: RUTH LANCE
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 317-585-0005