Healthcare Provider Details

I. General information

NPI: 1679797641
Provider Name (Legal Business Name): HEATHER MAUPIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 W MAIN ST SUITE 151
PLAINFIELD IN
46168-9700
US

IV. Provider business mailing address

1070 W MAIN ST SUITE 151
PLAINFIELD IN
46168-9700
US

V. Phone/Fax

Practice location:
  • Phone: 317-838-7100
  • Fax: 317-885-0417
Mailing address:
  • Phone: 317-838-7100
  • Fax: 317-885-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12010749A
License Number StateIN

VII. Legacy identifiers

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

# 1
Identifier271
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: