Healthcare Provider Details

I. General information

NPI: 1699211169
Provider Name (Legal Business Name): J. ORTHODONTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8071 TOWNSHIP LINE RD STE 100
INDIANAPOLIS IN
46260-2601
US

IV. Provider business mailing address

8071 TOWNSHIP LINE RD STE 100
INDIANAPOLIS IN
46260-2601
US

V. Phone/Fax

Practice location:
  • Phone: 317-731-5203
  • Fax: 317-731-5748
Mailing address:
  • Phone: 317-731-5203
  • Fax: 317-731-5748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12010266A
License Number StateIN

VIII. Authorized Official

Name: DR. SAMANTHA JONES
Title or Position: PRESIDENT
Credential: D.D.S., M.S.D.
Phone: 317-731-5203