Healthcare Provider Details

I. General information

NPI: 1144676123
Provider Name (Legal Business Name): INDIANA CENTER FOR SURGICAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6117 N COLLEGE AVE SUITE 4
INDIANAPOLIS IN
46220-2233
US

IV. Provider business mailing address

6117 N COLLEGE AVE SUITE 4
INDIANAPOLIS IN
46220-2233
US

V. Phone/Fax

Practice location:
  • Phone: 317-257-5442
  • Fax:
Mailing address:
  • Phone: 317-257-5442
  • Fax: 317-203-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DAVID MICHAEL MONTES
Title or Position: SOLE PROPRIETOR
Credential: DDS
Phone: 317-257-5442