Healthcare Provider Details

I. General information

NPI: 1619717618
Provider Name (Legal Business Name): BALAJI KOLASANI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8180 PENDLETON PIKE
LAWRENCE IN
46226-4015
US

IV. Provider business mailing address

8180 PENDLETON PIKE
LAWRENCE IN
46226-4015
US

V. Phone/Fax

Practice location:
  • Phone: 317-426-1562
  • Fax:
Mailing address:
  • Phone: 317-426-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12014415A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: