Healthcare Provider Details

I. General information

NPI: 1285847376
Provider Name (Legal Business Name): NORTHEAST ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 NORTH SHADELAND AVENUE
INDIANAPOLIS IN
46250
US

IV. Provider business mailing address

7205 NORTH SHADELAND AVENUE
INDIANAPOLIS IN
46250
US

V. Phone/Fax

Practice location:
  • Phone: 317-849-0110
  • Fax: 317-845-8845
Mailing address:
  • Phone: 317-849-0110
  • Fax: 317-845-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009571A
License Number StateIN

VIII. Authorized Official

Name: MRS. MARISA A WALKER
Title or Position: OWNER
Credential: DDS MSP
Phone: 317-849-0110