Healthcare Provider Details

I. General information

NPI: 1255702478
Provider Name (Legal Business Name): DENTAL PROFESSIONALS OF INDIANA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 E. MAIN ST. SUITE 104
PLAINFIELD IN
46168
US

IV. Provider business mailing address

2455 E. MAIN ST. SUITE 104
PLAINFIELD IN
46168
US

V. Phone/Fax

Practice location:
  • Phone: 317-991-1088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KENDRA WALKER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-8312