Healthcare Provider Details

I. General information

NPI: 1902457039
Provider Name (Legal Business Name): WILEY PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 W 30TH ST STE D
INDIANAPOLIS IN
46224-3057
US

IV. Provider business mailing address

6211 W 30TH ST STE D
INDIANAPOLIS IN
46224-3057
US

V. Phone/Fax

Practice location:
  • Phone: 317-299-0353
  • Fax:
Mailing address:
  • Phone: 317-299-0353
  • Fax: 317-298-8196

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. DILLON T WILEY
Title or Position: DENTIST / OWNER
Credential: DDS, MSD
Phone: 317-695-3604