Healthcare Provider Details

I. General information

NPI: 1881906634
Provider Name (Legal Business Name): CRATISA LATWANN CALDWELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8151 E 21ST ST
INDIANAPOLIS IN
46219
US

IV. Provider business mailing address

3952 N PARK AVE
INDIANAPOLIS IN
46205-2714
US

V. Phone/Fax

Practice location:
  • Phone: 317-353-8505
  • Fax:
Mailing address:
  • Phone: 317-956-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number6088
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011470A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: