Healthcare Provider Details

I. General information

NPI: 1063885820
Provider Name (Legal Business Name): MARK A. KAHN, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 W 30TH ST
INDIANAPOLIS IN
46224-3048
US

IV. Provider business mailing address

6211 W 30TH ST
INDIANAPOLIS IN
46224-3048
US

V. Phone/Fax

Practice location:
  • Phone: 317-299-0353
  • Fax:
Mailing address:
  • Phone: 317-299-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12009076
License Number StateIN

VIII. Authorized Official

Name: MARK A KAHN
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-299-0353