Healthcare Provider Details

I. General information

NPI: 1689678666
Provider Name (Legal Business Name): CHARLES EDWARD TOMICH DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9292 N MERIDIAN ST STE 210
INDIANAPOLIS IN
46260-1828
US

IV. Provider business mailing address

9292 N MERIDIAN ST STE 210
INDIANAPOLIS IN
46260-1828
US

V. Phone/Fax

Practice location:
  • Phone: 317-843-2204
  • Fax: 317-843-2478
Mailing address:
  • Phone: 317-843-2204
  • Fax: 317-843-2478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number12006898A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: