Healthcare Provider Details

I. General information

NPI: 1649359886
Provider Name (Legal Business Name): MIDWEST PERIODONTAL AND ORAL RECONSTRUCTION, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 INDIANA AVE
INDIANAPOLIS IN
46202-3106
US

IV. Provider business mailing address

508 INDIANA AVE
INDIANAPOLIS IN
46202-3106
US

V. Phone/Fax

Practice location:
  • Phone: 317-269-0402
  • Fax: 317-269-0405
Mailing address:
  • Phone: 317-269-0402
  • Fax: 317-269-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRIGITTE MILLS
Title or Position: DIRECTOR OF BUSINESS AFFAIRS
Credential:
Phone: 317-269-0402