Healthcare Provider Details

I. General information

NPI: 1699341420
Provider Name (Legal Business Name): SOMETHING COOL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 26TH ST STE 303
LAFAYETTE IN
47904-2893
US

IV. Provider business mailing address

415 N 26TH ST STE 303
LAFAYETTE IN
47904-2893
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-9319
  • Fax:
Mailing address:
  • Phone: 765-447-9319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: GLORIA ROYER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 765-447-9319