Healthcare Provider Details

I. General information

NPI: 1205353802
Provider Name (Legal Business Name): LORIE G BRINSON, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3934 W 96TH ST STE B
INDIANAPOLIS IN
46268-2928
US

IV. Provider business mailing address

3934 W 96TH ST STE B
INDIANAPOLIS IN
46268-2928
US

V. Phone/Fax

Practice location:
  • Phone: 317-228-0195
  • Fax: 317-228-0246
Mailing address:
  • Phone: 317-228-0195
  • Fax: 317-228-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number12010346A
License Number StateIN

VIII. Authorized Official

Name: DR. LORIE GOODPASTER BRINSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-228-0195