Healthcare Provider Details

I. General information

NPI: 1689165672
Provider Name (Legal Business Name): XU FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 FORT WAYNE AVE
INDIANAPOLIS IN
46204-1309
US

IV. Provider business mailing address

14536 STONEGATE CT
CARMEL IN
46032-9132
US

V. Phone/Fax

Practice location:
  • Phone: 317-602-4898
  • Fax: 317-559-7159
Mailing address:
  • Phone: 317-602-4898
  • Fax: 317-559-7159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. HAIFENG XU
Title or Position: DENTIST/OWNER
Credential: DDS, PHD
Phone: 317-602-4898