Healthcare Provider Details

I. General information

NPI: 1407996291
Provider Name (Legal Business Name): UNIVERSITY DENTAL SERVICE PLAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST ROOM 285B
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

1121 W MICHIGAN ST ROOM 285B
INDIANAPOLIS IN
46202-5211
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-6946
  • Fax: 317-274-6583
Mailing address:
  • Phone: 317-278-6946
  • Fax: 317-284-6583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MS. JILL ALLEN
Title or Position: CLINIC ADMINSTRATOR
Credential:
Phone: 317-278-6946