Healthcare Provider Details

I. General information

NPI: 1558785709
Provider Name (Legal Business Name): PLAINFIELD DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2014
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 EDWARDS DR UNIT 124
PLAINFIELD IN
46168-2791
US

IV. Provider business mailing address

824 EDWARDS DR UNIT 124
PLAINFIELD IN
46168-2791
US

V. Phone/Fax

Practice location:
  • Phone: 317-268-4593
  • Fax:
Mailing address:
  • Phone: 317-268-4593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12011426A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SARAH RENEE KINGSEED
Title or Position: DENTIST
Credential: D.D.S
Phone: 260-318-3151