Healthcare Provider Details

I. General information

NPI: 1730345646
Provider Name (Legal Business Name): NORTHSIDE ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E 86TH ST SUITE 15
INDIANAPOLIS IN
46240-1868
US

IV. Provider business mailing address

1010 E 86TH ST SUITE 15
INDIANAPOLIS IN
46240-1868
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-3396
  • Fax: 317-844-4776
Mailing address:
  • Phone: 317-844-3396
  • Fax: 317-844-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number54000837A
License Number StateIN

VIII. Authorized Official

Name: DR. JOHN H SLAVENS
Title or Position: OWNER
Credential: DDS, MSD
Phone: 317-844-3396