Healthcare Provider Details

I. General information

NPI: 1093164535
Provider Name (Legal Business Name): IDC DENTAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 E STOP 11 RD SUITE 11
INDIANAPOLIS IN
46237-8628
US

IV. Provider business mailing address

8445 S EMERSON AVE SUITE 101
INDIANAPOLIS IN
46237-9596
US

V. Phone/Fax

Practice location:
  • Phone: 317-889-6000
  • Fax: 317-889-1618
Mailing address:
  • Phone: 317-884-8633
  • Fax: 317-300-1896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12007400A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12012473A
License Number StateIN

VIII. Authorized Official

Name: DR. KELLIE MICHELLE SCHAUB
Title or Position: OWNER/PRESIDENT
Credential: DDS, MSD
Phone: 317-884-8633