Healthcare Provider Details

I. General information

NPI: 1538970934
Provider Name (Legal Business Name): MFDC OF INDIANA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 GEORGETOWN RD STE B
INDIANAPOLIS IN
46254-3717
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 502-254-8500
  • Fax:
Mailing address:
  • Phone: 502-254-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER PARDUE
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 502-548-2402