Healthcare Provider Details

I. General information

NPI: 1841143567
Provider Name (Legal Business Name): ORTHODONTIC EXPERTS OF INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5997 CENTRAL AVE
PORTAGE IN
46368-2944
US

IV. Provider business mailing address

5997 CENTRAL AVE
PORTAGE IN
46368-2944
US

V. Phone/Fax

Practice location:
  • Phone: 219-232-9056
  • Fax:
Mailing address:
  • Phone: 219-232-9056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: IRENA RAKHMETZYANOV
Title or Position: VP
Credential:
Phone: 224-628-0322