Healthcare Provider Details

I. General information

NPI: 1033309471
Provider Name (Legal Business Name): KEYSTONE ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 E 98TH ST SUITE 130
INDIANAPOLIS IN
46280-2005
US

IV. Provider business mailing address

3105 E 98TH ST
INDIANAPOLIS IN
46280-2005
US

V. Phone/Fax

Practice location:
  • Phone: 317-569-9977
  • Fax:
Mailing address:
  • Phone: 317-569-9977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12009805
License Number StateIN

VIII. Authorized Official

Name: DR. DONALD G. ANDERSON I
Title or Position: OWNER
Credential: D.D.S.,M.S.
Phone: 317-569-9977