Healthcare Provider Details

I. General information

NPI: 1275232555
Provider Name (Legal Business Name): INDY DENTAL AND ORAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 E 10TH ST
INDIANAPOLIS IN
46202-3728
US

IV. Provider business mailing address

1103 E 10TH ST
INDIANAPOLIS IN
46202-3728
US

V. Phone/Fax

Practice location:
  • Phone: 317-295-2211
  • Fax:
Mailing address:
  • Phone: 317-379-4328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ALEX WALKER
Title or Position: OWNER
Credential: DMD
Phone: 317-379-4328