Healthcare Provider Details

I. General information

NPI: 1366489627
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY WEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 W 10TH ST
INDIANAPOLIS IN
46234-2132
US

IV. Provider business mailing address

8930 W 10TH ST
INDIANAPOLIS IN
46234-2132
US

V. Phone/Fax

Practice location:
  • Phone: 317-271-6060
  • Fax: 317-271-6065
Mailing address:
  • Phone: 317-271-6060
  • Fax: 317-271-6065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK I THOMPSON
Title or Position: PEDIATRIC DENTIST
Credential: D.D.S.
Phone: 317-271-6060