Healthcare Provider Details

I. General information

NPI: 1689790552
Provider Name (Legal Business Name): INDIANA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7433
  • Fax:
Mailing address:
  • Phone: 317-278-3632
  • Fax: 317-274-2603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TINA D FOSTER
Title or Position: ASSISTANT DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 317-278-3632