Healthcare Provider Details

I. General information

NPI: 1053962654
Provider Name (Legal Business Name): FLAVIO DE ALCANTARA CAMEJO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-5111
  • Fax:
Mailing address:
  • Phone: 317-274-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberLDF230024
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: