Healthcare Provider Details

I. General information

NPI: 1700949724
Provider Name (Legal Business Name): SANDERSWEDDELLPEDIATRIC DENTALSPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 EAST 86TH STREET SUITE1
INDIANAPOLIS IN
46240-6859
US

IV. Provider business mailing address

860 EAST 86TH STREET SUITE1
INDIANAPOLIS IN
46240-6859
US

V. Phone/Fax

Practice location:
  • Phone: 317-575-2899
  • Fax: 317-575-2898
Mailing address:
  • Phone: 317-575-2899
  • Fax: 317-575-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAMES A WEDDELL
Title or Position: PARTNER
Credential: D.D.S.
Phone: 317-575-2899