Healthcare Provider Details

I. General information

NPI: 1790058741
Provider Name (Legal Business Name): STAR CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 W WASHINGTON ST
INDIANAPOLIS IN
46241-2147
US

IV. Provider business mailing address

5330 W WASHINGTON ST
INDIANAPOLIS IN
46241-2147
US

V. Phone/Fax

Practice location:
  • Phone: 317-414-8822
  • Fax:
Mailing address:
  • Phone: 317-414-8822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12011343A
License Number StateIN

VIII. Authorized Official

Name: ESTHER GHEBREMICHAEL
Title or Position: OWNER
Credential:
Phone: 317-414-8822