Healthcare Provider Details

I. General information

NPI: 1366291056
Provider Name (Legal Business Name): PLAINFIELD PARK PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 CLARKS CREEK RD STE 102
PLAINFIELD IN
46168-8767
US

IV. Provider business mailing address

6100 CLARKS CREEK RD STE 102
PLAINFIELD IN
46168-8767
US

V. Phone/Fax

Practice location:
  • Phone: 317-900-1665
  • Fax:
Mailing address:
  • Phone: 317-900-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric 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: LESA ALLISON
Title or Position: OWNER
Credential: DDS, MSD
Phone: 317-900-1665